1. Good Hospital Practice 2012
Medication safety
Good Hospital Practice 2012

2. Objectives of this presentation
To highlight the importance of ensuring the safe use of medications in Medical City
To present the roles of the Medical City staff in promoting medication safety
To discuss how to report, monitor and prevent adverse drug reactions

3. What is a medication error?
"A medication error is 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. “
 National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) definition of a medication error. Specifically, a medication error is "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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

4. Incidence of preventable adverse drug events
Each year
380,000 – 450,000 in hospitals
800,000 in long-term care facilities
530,000 among outpatients
Institute of Medicine Report Brief, July 2006 at

5. What factors are related to medication errors?
professional practice,
health care products, procedures, and systems of
prescribing;
order communication;
product labeling, packaging, and nomenclature;
compounding;
dispensing;
distribution;
administration;
education;
monitoring; and use."

6. We have about 2,000 admissions every month
We give about 3 to 5 medications per patient
Even if our correct medication rate is 99% we would still expect 60 to 100 medication errors per month.

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

8. Relationship between ADEs, potential ADEs, and medication errors
Relationship between ADEs, potential ADEs, and medication errors. (Reproduced with permission from Morimoto T, Gandhi T, Seger A, Hsieh T, Bates D. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care 2004; 13:306–14.)

9. Mistakes may be defined as errors in the planning of an
action and may be knowledge-based (e.g. giving a
medication without having established whether the
patient is allergic to that medication) or rule-based. Rulebased
errors can further be classified as either the
misapplication of a good rule (e.g. injecting a medication
into the non-preferred site) or the application of a bad
rule or the failure to apply a good rule (e.g. using
excessive doses of a drug). Slips and lapses are errors in
the performance of an action – a slip through an
erroneous performance (e.g. writing the more familiar
‘chlorpropramide’ instead of ‘chlorpromazine’) and a lapse
through an erroneous memory (giving a drug that a
patient is already known to be allergic to). Technical
errors are the result of a failure of a particular skill (e.g. in
the insertion of a cannula) and are therefore a subset of
slips (skill-based errors).
The classification of medication errors based on a psychological approach. (Reproduced with permission from Ferner RE,Aronson J. Clarification of terminology in medication errors. Definitions and classification. Drug Saf 2006; 29:1011–22.)

10. Prescribing errors
Lack of knowledge of the prescribed drug, its recommended dose, interactions with food and drugs
Lack of knowledge of patient details
Illegible handwriting.
Inaccurate medication history taking.
Confusion with the drug name.
Inappropriate use of decimal points. A zero should always precede a decimal point (e.g. 0·1). Similarly, tenfold errors in dose have occurred as a result of the use of a trailing zero (e.g. 1·0).
Use of abbreviations (e.g. AZT has led to confusion between zidovudine and azathioprine).
Use of verbal orders.

11. Administration errors
Dispensing errors
Drug interchange due to look alike / sound alike drugs
Wrong patient, wrong dose
Administration errors
Drug interchange due to look alike / sound alike drugs
Wrong patient, wrong dose

12. Common errors resulting in ADRs
1. Math error when calculating dose.
2. Nurse uses wrong patient weight.
3. Nurse does not check patient’s armband.
4. Nurse draws up wrong amount in syringe.
5. Nurse administers wrong strength bolus.
6. No double check of pump completed.
7. Uses estimated patient weight.
8. Uses inaccurate patient weight.
9. Double check of dose is only cursory.

13. The role of ALL doctors
Choose medications wisely. Limit the number of medications to avoid adverse drug events.
Check for drug allergies and interactions always.
Write all prescriptions and medication orders legibly.
Ask your nurse to READ BACK your written orders to avoid medication errors.
Order medications that are in the formulary. Formulary drugs are reviewed for efficacy and safety. They are cheaper than non-formulary brands.
Use the generic name of the drug AND write it in FULL.
Allow generic substitution of ordered medications. Do not insist on your brand. Do not make your patients pay more and wait longer for emergency drug purchases.

14. The role of ALL doctors
Write the clinical indication for the drug, e.g., leurpolide to block testosterone. Writing the indication helps reduce wrong drug administration and educates patients and the care team.
Compare the patient’s list of meds being taken at home with the list of meds to be ordered on admission and reconcile the two lists. Communicate the finalized list to healthcare team members and the patient. Repeat the process whenever meds are added or removed. .
Respond to pharmacists’ queries promptly. Pharmacists are required to review every new drug order for therapeutic appropriateness, correct dosing, interactions with food and drugs, etc

15. The role of ALL doctors
Do not use Forbidden Abbreviations. Residents and nurses will ask you to replace all Forbidden Abbreviations.
Avoid phone orders save for extreme emergency and sign the orders within 24 hours.
Write and reconcile all drugs after a procedure. “Resume all meds” is an illegal order and will not be followed.
Do not allow brought in medications to be taken during confinement, except for a few exempted drugs (mostly topicals). “Meds care of patient” is an illegal order and will not be followed.
Report all adverse drug events to the Therapeutics Committee.

16. Some Forbidden Abbreviations

17. 9 reasons why you should watch out for ADRs in older patients
Smaller bodies and different body composition
Decreased ability of the liver to process drugs
Decreased ability of the kidneys to clear drugs out of the body
Increased sensitivity to many drugs
Decreased blood pressure-maintaining ability
Decreased temperature regulation.
More diseases than affect response to drugs
More drugs being taken, thus more ADRs and interactions
Inadequate testing of drugs in elderly before regulatory approval

18. The role of nurses
Read back all written and verbal drug orders, clearly repeating the generic name of the drug, the dosage ordered, and indication. Request for confirmation from the prescriber.
Refer to the head nurse and pharmacist when faced with conflicting information from prescribers and published drug literature.
When administering medications, confirm with the patient his or her identity AND the generic and brand name of the medication you are administering to him or her.

19. The role of nurses
4. Follow all procedures on drug calculations, drug preparation and drug administration to the letter. No shortcuts.
5. Ensure that the medications are given on a timely basis and as prescribed.
6. Store all medications according to policy.
7. Be particularly careful in preparing, administering and storing drugs in the DrugWatch list.
8. Monitor all first dose effects.
9. Ensure medication reconciliation at all critical points during confinement.
10. Verify and replace all forbidden abbreviations.

20. The role of nurses
11. Report all adverse drug events to the Therapeutics Committee.
12. Report all medications errors and near misses to your head nurse.
13. Educate patients about their medications and about medication safety.

21. What are adverse drug reactions (ADRs)?
     An adverse drug reaction is any unexpected, unintended, undesired, or excessive response experienced following the administration of a drug or combination of drugs that is associated with ANY ONE of the following:
A.    Requires discontinuing the drug, or changing the drug therapy,
B.    Requires significant dose modification,
C.    Necessitates admission (for ambulatory patients) or significantly prolongs the length of stay (for inpatients)
D.    Necessitates supportive treatment,
E.     Significantly complicates diagnosis or negatively effects prognosis
F.     Results in temporary or permanent harm, disability, or death
G. Is a therapeutic failure.

22. You must report suspected ADRs
ADRs may or may not be related or caused by drug intake and this may be difficult to determine.
The important thing is to alert the Medical City that a patient on a particular set of drugs has experienced an adverse event so that appropriate study can be carried out.

23. What should you do if you suspect an ADR?
Stop the medication immediately.
Report the ADR by filling out the ADR Reporting Form and hand it over to the Clinical Pharmacist. Any hospital staff member, even if unsure, may report a potential ADR preferably while the patient involved is still confined. Reporting may be done anonymously.
Coordinate with the Clinical Pharmacist in managing the patient’s ADR.

24. How will your report be handled?
The Clinical Pharmacists, through evaluative questions and professional judgment, initially screens and assesses your ADR report. Once verified, they will advise you on how to manage the patient’s ADR.
Your report goes into the Medical City ADR database maintained by central pharmacy.
ADR reports are monitored and analyzed and provide the basis for educational programs to help the hospital staff in avoiding ADR occurrence and improving patient care
ADR reports are also sent to the manufacturer and/or BFAD.

25. The role of pharmacists
Follow all procedures on drug storage, labelling, dispensing, recall and disposal.
Be particularly careful in the dispensing and storing of drugs in the DrugWatch list.
Ensure medication reconciliation at all critical points during confinement.
Regularly conduct random sampling of charts in their units and check for
Timeliness of nurses’ accomplishment of physicians’ medication orders
Legibility of physician’s orders,
Completeness of medication orders
Completeness of prescriptions .

26. The 2012 DrugWatch List Look-alike and sound-alike drugs
Drugs with narrow therapeutic index
Inotropic agents
Insulin preparations
Chemotherapeutic agents
Dangerous Drugs
Concentrated electrolytes
Non-steroidal anti-inflammatory drugs (NSAIDs)
Anticoagulants
Total parenteral nutrition given through the central line

27. The role of pharmacists
5. Alert the Therapeutics Committee when look-alike and sound-alike drugs are admitted into the formulary in order to take steps to identify these drugs as “high risk” for potential errors.
6. When look-alike and sound-alike drugs are allowed on the formulary, or are ordered on a non-formulary basis, they should be identified as being medications at "high risk" for potential error and extra steps should be taken to assure safety in ordering, dispensing and administering such products.
7. If a forbidden abbreviation is used, verify the prescription order with the prescriber prior to its being filled..

28. The role of pharmacists
8. Review all new drug orders and prescriptions in terms of
a) the appropriateness of the drug, dose, frequency, and route of administration;
b) therapeutic duplication;
c) real or potential allergies or sensitivities;
d) real or potential interactions between the medication and other medications or food;
e) variation from organization criteria for use;
f ) patient’s weight and other physiological information; and
g) other contraindications.

29. The role of pharmacists
9.Report all medication errors and near misses
10. Report all adverse drug events
11. Educate staff and patients about medications safety

30. Examples of best practices in combating medication errors
Standardization/simplification of drug handling
Eliminate look-alike/sound-alike drugs
Forcing functions (lock-outs/time-outs)
Checklists
Structured communication (read back orders to patients or to doctors)

31. Hierarchy of Barriers for Error Reduction
Most Effective
Physical (Forcing Functions)
Natural (Distance, Time)
Information (Labels, Signs)
Measures (Tests, Inspections)
Knowledge (Training, Coaching)
Administrative (Checklists, Policies)
Least Effective

32. Final take home messages

33. Reducing medication errors
Prescribers:
use sound med reconciliation techniques
avoid verbal orders except in emergencies
avoid abbreviations (U for units seen as a 0)
inform patients of indications for all medications
work as a team with pharmacists and nurses
use special caution with DrugWatch medications
report errors and ADEs

34. Reducing medication errors
Pharmacists:
monitor the medication safety literature
in conjunction with doctors and nurses, develop, implement, and follow medication reconciliation
verify the accurate entry of data on new prescriptions (clarify all abbreviations);
report errors and near misses to MQIO

35. Reducing medication errors
Nurses:
foster a commitment to patients’ rights (YOU are the patient’s advocate)
be prepared and confident in questioning prescribers about their medication orders
participate in, or lead, medication safety projects
support a culture that values accurate reporting of medication errors

36. The Science of Safety The key to improving safety lies not in
changing the human
condition, but in
changing the conditions under which humans work
Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990

37. Are you a safe medication practitioner?
Which of the following are in the Medical City Drugwatch list?
Potassium chloride
Insulin
Magnesium sulfate
All of the above
Answer: ? D
Which of the following practice/s promote/s medication safety?
a. Writing orders and prescriptions legibly
b. Insisting that the pharmacy stock up your brand of antibiotic
c. Arranging drugs alphabetically by brand names
d. All of the above
A. Choices b and c lead to mixing up sound-alike drugs.

38. Are you a safe medication practitioner?
3. Which of the following will lead you to report a possible ADR?
a. The drug needed to be stopped or changed.
b. A significant dose modification is required.
c. The patient suffered temporary or permanent harm.
d. All of the above
Answer: ? D
4. When reporting a possible ADR
a. You must be absolutely sure that it was caused by a drug.
b. You must always sign the report with your name.
c. You must immediately file the report while patient is confined.
d. all of the above
Answer:?
C. You don’t have to be sure of drug causation and you can file the report anonymously.

39. Are you a safe medication practitioner?
5. Which of the following is an inexpensive but effective intervention to help the pharmacist screen for medication errors?
a. Write the side effects on the prescription
b. Write the drug indication on the prescription
c. Avoid the forbidden abbreviations.
d. all of the above
Answer: ? B
6. Which among the following is a/are good way/s to prevent ADRs?
a. Have nurses read back orders to MDs
b. Reprimand nurses who make erroneous computations.
c. Suspend residents who write illegibly. A

40. Are you a safe medication practitioner?
7. Which strategy is the LEAST effective way for preventing ADRs?
a. Physical (Forcing Functions)
b. Natural (Distance, Time)
c. Information (Labels, Signs)
d. Administrative (Checklists, Policies)
Answer: ?
D. Forcing functions are the most effective. Policies can be broken.
8. The following is/are reason/s why elderly are more prone to ADRs:
a. Old people have trouble remembering their drugs.
b. Old people have poor liver and kidney drug handling capacities.
c. Old people have lower fat deposits in which drugs are stored.
d. All of the above D

41. Are you a safe medication practitioner?
8 out of 8 – your patients are safe from medication errors!
6 or 7 out of 8 – your patients safety level is above average
4 or 5 out of 8 – your patients safety level is just about barely adequate
2 or 3 out of 8 – you can improve the safety of your medication practice!*
0 or 1 out of 8 – let us try again; meanwhile try to keep your medication use on patients to the bare minimum!*
* Please go over the slides again.

42. Summary of this presentation
Our ability to ensure the safe use of medications can spell the difference between health and illness, even life and death, for many patients.
Our staff have critical roles to play in promoting medication safety
We must report, monitor and prevent adverse drug reactions to spare our patients from further harm.

43. This SIM Card certifies that ______(please overwrite with your name, thank you)__, MD has successfully completed the Self Instructional Module on Medication Management and Use (Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin President and CEO Director, Medical Quality Improvement