MEDICATION ERROR

AGA KHAN HOSPITAL (22-JAN-2014)

Presentation By: Beenish Iqbal Arain

Objectives

Definitions Causes Stages of Medication error How to decrease Medication error

Dr:Beenish Iqbal Arain

Medication Error Definition Medication errors, broadly defined as any error in

the prescribing, dispensing, or administration of a drug,

Medical errors are often described as human errors in healthcare

> Such events may be related to:1) professional practice

2) health care products

3) Procedures and systems

4) product labeling, packaging, and nomenclature

5) dispensing

6) distribution

7) administration

8) education

9) monitoring

Dr:Beenish Iqbal Arain

Some reasons errors occur verbal orders poor communications within healthcare team poor handwriting improper drug selection missing medication drug interactions availability of floor stock (no second check) look alike / sound alike drugs hectic work environment lack of computer decision support

Dr:Beenish Iqbal Arain

Stages of Medication Error Phase 1- Ordering/Prescribing Phase 2- Dispensing Phase 3- Administration Phase 4- Monitoring

DR:Beenish Iqbal Arain

Ordering/prescribing

inadequate knowledge about drug indications and contraindications

not considering individual patient factors such as allergies, pregnancy, co-morbidities, other medications

wrong patient, wrong dose, wrong time, wrong drug, wrong route

inadequate communication (written, verbal) documentation - illegible, incomplete, ambiguous mathematical error when calculating dosage incorrect data entry when using computerized

prescribing e.g. duplication, omission, wrong number

DR:Beenish iqbal Arain

Prescription error example

Dispensing

inexperience rushing doing two things at once interruptions fatigue, boredom, being on “automatic pilot”

leading to failure to check and double-check lack of checking and double checking habits poor teamwork and/or communication

between colleagues Too much phone calls Dr:Beenish Iqbal Arain

Dispensing error example

Look alike/ sound alike

Sound alike Look alike

Zantac/Zyrtec Rotavir/Ritnovir Folic acid/ Folinic acid ephederine/ epinephrine Doxorubicin/

Daunorubicin Celebrex/ cerebryx

DR:Beenish iqbal Arain

Cyclogest/paracup

Look alike examples

Administration

wrong patient wrong route wrong time wrong dose wrong drug omission, failure to administer inadequate documentation

Administration error example

Monitoring

lack of monitoring for side-effects drug not ceased if not working or

course complete drug ceased before course completed drug levels not measured, or not

followed up on communication failures

Dr:Beenish Iqbal Arain

What Can You Do To Decrease Medication Errors?

Check and double check, if in doubt check it out, again!

Follow the 5 R’s: right patient, right drug, right dose, right time, right route

Never assume, “pharmacy put the medication in the drawer so this must be right”, pharmacy makes errors too.

Never assume, “the resident ordered this large dose so it must be right”, Residents make errors too.

Know the correct mg/kg dose of medications you are administering.

Know why you are giving the medication, the expected action, and any potential side effects.

DR:Beenish Iqbal Arain