1. Medication Safety
Dr. Kanar Hidayat

2. 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.  

3. 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.

4. 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)

5. 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

6. Example

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

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

9. 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

10. Look-a-like and sound-a-like medications

11. 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

12. 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

13. 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

14. Role of Electronic Medical Record (EMR)

15. 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

16. Questions?