Medication Safety Dr. Kanar Hidayat 2018-2019

Medication Safety Programme This programme aims to improve medication safety in the health and disability sector by focusing on reducing harm from medication errors and addressing unwarranted variation and inequities to improve consumer outcomes.  

Errors Adverse Drug Event: an injury resulting from a medication or lack of intended medication Improper Dose Error: administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient Medication Error: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

Patient Groups At Risk Patients on multiple medications Patients with another condition, e.g. renal impairment, pregnancy Patients who cannot communicate well Patients who have more than one doctor Patients who do not take an active role in their own medication use Children and babies (dose calculations required)

Medication Reconciliation The process of identifying the most accurate list of all medications used by a patient The list contains also: name, dosage, frequency and route To provide correct medications for patients anywhere within the health care system Reconciliation: comparing patient’s current list against admission, transfer and/or discharge

Example

Prescribing Error Incorrect drug selection based on: Indications Contraindications Known allergies Existing drug therapy Dose and Dosage form Quantity Route Concentration Instructions for use

Key Positions Responsible persons who: Prescribe Prepare Dispense Administer Monitor drug therapy

How can prescribing go wrong? Lacking of 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 - incomplete, ambiguous Mathematical error when calculating dosage Incorrect data entry when using computerized prescribing e.g. duplication, omission, wrong number

Look-a-like and sound-a-like medications

Medication history taking Include name, dose, route, frequency, duration of every drug Enquire about recently ceased medications Ask about over-the-counter medications, dietary supplements and alternative medicines Make sure what patient actually takes matches your list: be particularly careful across transitions of care practice medication reconciliation at admission to and discharge from hospital Look up any medications you are unfamiliar with Consider drug interactions, medications that can be ceased and medications that may be causing side- effects Always include allergy history

Staff Errors Inexperience Rushing Doing two things at once Interruptions Lack of checking and double checking habits Poor teamwork and/or communication between colleagues Reluctance to use memory aids

Monitoring errors 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

Role of Electronic Medical Record (EMR)

Summary Medications can greatly improve health when used wisely and correctly Medication error is common and is causing preventable human suffering and financial cost Remember that using to help patients is not a risk-free activity Know your responsibilities and work hard to make medication use safe for your patients Read chapter 10 Medication Safety, The Pharmacy Informatics Primer, Doina Dumitru

Questions?