1. Chapter 6
Medication Safety

2. Learning Objectives
Understand the extent and effect of medical errors on patient health and safety
Describe how and to what degree medication errors contribute to medical errors
*List examples of medication errors commonly seen in practice settings
Apply a systematic evaluation of opportunities for medication error to a pharmacy practice model
Identify the common medication error–reporting systems available

3. Medical Errors
A medical error is any circumstance, action, inaction, or decision related to healthcare that contributes to an unintended health result
Most of what is known about medical errors comes from information collected in the hospital setting
hospital data make up only a part of a much larger picture
most healthcare is administered in the outpatient, office-based, or clinic setting
Medical errors are difficult to define
possible causative circumstances are infinite

4. Medical Errors
Medical-related lawsuits show the scope of medical errors in the United States
One large government studied only medical errors during hospitalization
44,000 to 98,000 people in the U.S. die each year as a result of medical errors (greater than the risk of death from accident, diabetes, homicide, or human HIV and AIDS)
multiple sources for potential medical errors exist

5. Discussion What are some examples of medical errors?
Edited by Dr. Ryan Lambert-Bellacov

6. Discussion What are some examples of medical errors?
Answer: Lab tests drawn at the wrong time (inaccurate results), major surgical errors ending in injury or death

7. Medication Errors
A medication error is a medical error in which the source of error or harm includes a medication
Like medical errors
medication errors have no specific definition because the possible causes can be endless
information on the effect of medication errors comes mostly from studies done in the hospital setting
Medication-related deaths are estimated at about 7,000 each year

8. Medication Errors
Fewer studies of medication errors in community practice exist
an estimated 1.7% of all prescriptions dispensed in a community practice setting contain a medication error (4 of every 250 prescriptions)
Not all medication errors result in harm to a patient
65% of the medication errors detected had a meaningful effect on the patient’s health

9. Medication Errors Measuring results of medication errors
lost lives
disabled patients
time lost from work or school
cost to the healthcare system
billions of dollars
physician visits
additional hospitalizations
emergency room visits
admissions to long-term care
continuation of disease

10. Healthcare Professional’s Responsibility
Working in healthcare means making a commitment to “first do no harm”
The profession of pharmacy exists to safeguard the health of the public
Healthcare must focus on treating the patient
to the best possible outcome
by the safest possible means
No “acceptable” level of medication error exists
effect of a potential medication error on the patient cannot be predicted
each step in fulfilling medication orders should be reviewed with a 100% error-free goal

11. Healthcare Professional’s Responsibility
Safety
Note
The only acceptable level of medication errors is zero.
Edited by Dr. Ryan Lambert-Bellacov

12. Healthcare Professional’s Responsibility
MA’s can identify potential patient sources of medication error
careful listening and observation during a patient or medical staff interaction
notifying the pharmacist
MA’s make a significant contribution to patient safety
constant surveillance for potential sources of medication error

13. Tips for Reducing Medication Errors
Always keep the prescription and the label together
Know common look-alike and sound-alike drugs
Keep dangerous or high-alert medications in a separate storage area
Always question bad handwriting
Prescriptions/orders should be correctly spelled with drug name, strength, appropriate dosing, quantity or duration of therapy, dose form, and route
Use the metric system

14. Tips for Reducing Medication Errors
Question uncommon abbreviations
Be aware of insulin mistakes
Keep the work area clean and uncluttered
Verify information
Labels should always be compared with the original prescription by at least two people

15. Healthcare Professional’s Responsibility
Safety
Note
If information is missing from a medication order, never assume. Obtain the missing information from the prescriber.
Edited by Dr. Ryan Lambert-Bellacov

16. Tips for Reducing Medication Errors: MA’s
Use the triple-check system
Regularly review work habits
Verify information with the patient or caregiver
Observe and listen
Keep your work area free of clutter
Edited by Dr. Ryan Lambert-Bellacov

17. Patient Response
Most patients have the intended therapeutic response expected from the medication
Unique physical and social circumstances make it impossible to predict which
medication errors may result in no substantial harm
may result in death

18. Physiological Causes of Medication Errors
Each patient has a unique response to medication
genetically unique
speed at which medications are removed from body varies
Even a problem caught and corrected before harm occurs is still considered a medication error

19. Social Causes of Medication Errors
Outpatients can contribute to medication errors through incorrect administration
Social causes of error include:
failure to follow medication therapy instructions because of cost
noncompliance
failure to receive therapy
misunderstanding instructions (language barriers)
Edited by Dr. Ryan Lambert-Bellacov

20. Social Causes of Medication Errors
Patients can contribute to medication errors by
forgetting to take a dose or doses
taking too many doses
dosing at the wrong time
not getting a prescription filled or refilled in a timely manner
not following directions on dose administration
terminating the drug regimen too soon

21. Social Causes of Medication Errors
Social causes may result in an adverse drug reaction, or a toxic dose
Over 50% of patients on necessary long-term medication are no longer taking their medication after 1 year
All of these social circumstances would be considered medication errors

22. Categories of Medication Errors
Possible causes of a medication error are numerous
Categorizing errors into types aids in identification and prevention of possible causes
Categories focus on grouping errors under a set of common definitions
Edited by Dr. Ryan Lambert-Bellacov

23. Categories of Medication Errors
omission error: a prescribed dose is not given
wrong dose error: a dose is either above or below the correct dose by more than 5%
extra dose error: a patient receives more doses than were prescribed by the physician
wrong dose form error: dose form or formulation that is not the accepted interpretation of the physician order
wrong time error: drug is given 30 minutes or more before or after it was prescribed

24. Categories of Medication Errors
Errors can be classified by what causes the failure of the desired result
Errors can be categorized within three basic definitions of failure:
human failure
technical failure
organizational failure

25. Categories of Medication Errors
Human failure is a failure that occurs at an individual level
pulling a medication bottle from the shelf based on memory, without cross-referencing the bottle label with the medication order/prescription
errors made by the patient such as non-compliance to prescribed drug therapy
Technical failure is a failure resulting from location or equipment
incorrect reconstitution of a medication because of a malfunction of a sterile-water dispenser
failure to properly operate automated equipment

26. Root Cause Analysis of Medication Errors
Root cause analysis is a logical and systematic process used to help identify what, how, and why something happened to prevent reoccurrence
With basic principles of root cause analysis, any person can
examine his or her own work flow to determine the opportunities for potential error
determine what type of failure the potential error may be
create a list of specific potential causes

27. Root Cause Analysis of Medication Errors
Identifying specific potential causes allows a person to take specific actions to prevent the potential error
Actions taken improve the quality of work being done
Common causes of medication error by handlers and preparers include:
assumption error
selection error
capture error

28. Root Cause Analysis of Medication Errors
assumption error: an essential piece of information cannot be verified and is guessed or presumed
misreading an abbreviation on a prescription
selection error: two or more options exist, and the wrong option is chosen
using a look-alike or sound-alike drug instead of prescribed drug
capture error: focus on a task is diverted elsewhere and an error goes undetected
something captures the person’s attention, preventing the person from detecting the error or causing an error to be made

29. Root Cause Analysis of Medication Errors
Safety
Note
Maintaining focused attention when filling prescriptions is important to avoid errors.
Edited by Dr. Ryan Lambert-Bellacov

30. Prescription-Filling Process in Community and Hospital Pharmacy Practice
Review for potential causes of medication error begins with outlining work tasks in a step-by-step manner
Each step in this process can be a
source of medication error
place where pharmacy personnel can correct a medication error

31. Prescription-Filling Process in Community and Hospital Pharmacy Practice
Safety
Note
Each person who participates in the filling process has the opportunity to catch and correct a medication error.
Edited by Dr. Ryan Lambert-Bellacov

32. Prescription-Filling Process
Safety
Note
Outdated prescriptions should not be filled.
Edited by Dr. Ryan Lambert-Bellacov

33. Prescription-Filling Process
Safety
Note
A prescriber’s signature is required for a prescription to be considered valid.
Edited by Dr. Ryan Lambert-Bellacov

34. Prescription-Filling Process Step 1
Prescribing errors include:
poor handwriting
using nonstandard abbreviations
confusing look-alike and sound-alike drug names
wrong drug
using “as directed” instructions
Edited by Dr. Ryan Lambert-Bellacov

35. Prescription-Filling Process Step 1
Edited by Dr. Ryan Lambert-Bellacov

36. Prescription-Filling Process
Safety
Note
A leading zero should precede values less than one, but a zero should not follow a decimal if the value is a whole number. A tenfold error occurs if the decimal point is not detected.
Edited by Dr. Ryan Lambert-Bellacov

37. Prescription-Filling Process Step 1
Opportunities for medication errors increase with the number of medications a patient takes
common with many older patients
Profile review for every prescription should include:
check for existing allergies and multiple drug therapy
check for drug interactions or duplication of therapy
Edited by Dr. Ryan Lambert-Bellacov

38. Prescription-Filling Process
Safety
Note
Check the patient profile for existing allergies or possible drug interactions.
Edited by Dr. Ryan Lambert-Bellacov

39. Prescription-Filling Process
:Retrieve Medication
Products can contribute to errors with
look-alike labels
similarities in brand or generic names
similar pill shapes or colors
Use NDC numbers, drug names, and other information to verify selection of the correct product
use both the original prescription and the generated label when selecting a manufacturer’s drug product from the storage shelf
use NDC numbers as a cross-check

40. Prescription-Filling Process
Step 5: Fill or Compound Prescription
Calculation and substitution errors are sources of medication errors
write out the calculation and have a second person check the answer
Take care when reading labels and preparing compounded products

41. Medication Error Prevention
Preventing medication errors means
carefully examining potential points of failure
using available resources to verify information given or decisions made
Drug identification is the most common error in dispensing and administration

42. Medication Error Prevention
Safety
Note
Incorrect drug identification is the most common error in dispensing or administration.
Edited by Dr. Ryan Lambert-Bellacov

43. Medication Error Prevention
Many medication errors occur during prescribing and administration
Prescribers are responsible for ensuring the “five Rs” or five rights
the right drug
for the right patient
at the right strength
given by the right route
administered at the right time

44. Innovations to Promote Safety
The physical pharmacy work setting can have a major contribution to the overall safety of any work environment
Automate and bar code all fill procedures
Maintain a clean, organized, orderly work area
Provide adequate storage areas
Encourage prescribers to use common terminology and only safe abbreviations
Provide adequate computer applications and hardware

45. Innovations to Promote Safety
Innovations can minimize possibility of errors
In community pharmacy, redesigned packaging helps patients take medication safely
Target ClearRx packaging helps patients manage their medications
colored rings help patients identify medications intended for each family member
clear, easy-to-read label for patient administration instructions and cautions
includes a pullout patient information card or printout
Learn more about the Target label design

46. Innovations to Promote Safety
In hospital pharmacy, integrated computerized filling systems allow institutions to
improve efficiency
redirect resources

47. Medication Error and Adverse Drug Reaction Reporting Systems
The first step in prevention of medication errors is collection of information
Fear of punishment is a concern with errors
people may decide not to report an error at all
allows the same error to occur again and again
Anonymous (no-fault) reporting systems have been established
focus on fixing the problem, not fixing the blame

48. State Boards of Pharmacy
More than 20 states have mandatory error-reporting systems
most state officials admit medical errors are still under-reported mostly because of fear of punishment
Some states have worked to reduce the fear of reporting
allow pharmacists to document errors and error-prone systems without worry of punishment
most boards of pharmacy will not punish pharmacists for errors

49. State Boards of Pharmacy
Pharmacy technicians are an integral part of the error identification, documentation, and prevention process
The final and most important piece of medication error reporting is informing the patient that a medication error has taken place
commonly the task of the pharmacist

50. State Boards
The circumstances leading to the error should be explained completely and honestly
Patients should understand
the nature of the error
what if any effects the error will have
how they can become actively involved in preventing errors in the future
People are more likely to forgive an honest error

51. Joint Commission on Accreditation for Healthcare Organizations
Organizations can create a centralized point through which all members may channel error information safely
The Sentinel Event Policy was created by the Joint Commission on Accreditation for Healthcare Organizations (JCAHO) in 1996
A sentinel event is an unexpected occurrence involving death or serious physical or psychologic injury

52. Joint Commission on Accreditation for Healthcare Organizations
When a sentinel event is reported, the organization is expected to
analyze the cause of the error (perform a root cause analysis)
take action to correct the cause
monitor the changes made
determine whether the cause of the error is eliminated
Accreditation of hospitals depends on demonstrating an effective active error–reporting system
Learn more about the Joint Commission International Center for Patient Safety