Improving Medication

Safety
Training & Education Department
Jhessie L.
Abella
Learning Objectives
 To provide an overview of medication safety
 To encourage you to continue to learn and practice ways to i
mprove the safety of medication use
 Define medication errors and classify their significance
 Understand the extent of medication errors and their impact on
patient care
 Discuss the many factors that contribute to errors and the
impulse to “place blame” on healthcare workers
 Examine approaches to minimize the risk of medication
errors
Knowledge Requirements
 Understand the scale of medication error
 Understand the steps involved in a patient using me
dication
 Identify factors that contribute to medication error
 Learn how to make medication use safer
 Understand a doctor’s responsibilities when using
medication
Definitions
 Side-effect: a known effect, other than that primarily intended
relating to the pharmacological properties of a medication
 e.g. opiate analgesia often causes nausea
 Adverse Reaction: unexpected harm arising from a justified
action where the correct process was followed for the context i
n which the event occurred
 e.g. an unexpected allergic reaction in a patient taking a medicati
on for the first time
 Error: failure to carry out a planned action as intended or a
pplication of an incorrect plan
 Adverse Event: an incident that results in harm to a patient
WHO: World alliance for patient safety taxonomy
Definitions
 An Adverse Drug Event:
 may be preventable (usually the result of an error) or
not preventable (usually the result of an adverse drug
reaction or side-effect)
 a medication error may result in …
 an adverse event if a patient is harmed a near miss if a
patient is nearly harmed or neither harm nor potential f
or harm medication errors are preventable
 Defining Medication Errors

 "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 m
ay be related to:
 professional practice  dispensing
 health care products  distribution
 procedures and systems  administration
 product labeling, packaging  education
and nomenclature  monitoring
National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at
http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.
 How medical errors rank as cause of mortality

Heart Accidents
616,067 123,706

Cancer Medical
562,875 Errors
~100,000
Stroke Alzheimer's
135,952 74,632

Lung Diabetes
127,924 71,382
www.cdc.gov/nchs/fastats. Accessed Jan 2012. Based on 2007 data.
Some Reasons Errors Occur

 verbal orders
 poor communications within healthcare team
 poor hand writing
 improper drug selection
 missing medication
 incorrect scheduling
 polypharmacy
 drug interactions
 availability of floor stock (no second check)
 look alike / sound alike drugs
 hectic work environment
 lack of computer decision support
Which patients are most at risk of
medication error?
 patients on multiple medications
 patients with another condition, e.g. renal i
mpairment, 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)
In what situations are staff most likely
to contribute to a medication error?
 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
 Reluctance to use memory aids
Why have a standard about medication safety?
Where do errors occur ?

Prescribing Transcription Dispensing Administering

39% 12% 11% 38%

52% of prescribing errors reach Only 2% of administration

the patient errors intercepted.
Written Medication Orders: Illegible Handwriting
 16% of physicians have illegible handwriting.1
 Common cause of prescribing errors.2, 3, 4
 Delays medication administration.5
 Interrupts workflow. 5
 Prevalent and expensive claim in malpractice cases.3

1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral
JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14; 5. Cohen MR.
Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
LEGIBILITY AND DRUG
Unasyn or Vancomycin?
NAMES

Protonix or Protamine?

Capoten or Cozaar?
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Written Medication Orders: Decimals
• Avoid whenever possible1
– Use 500 mg for 0.5 g
– Use 125 mcg for 0.125 mg
• Never leave a decimal point “naked” 1, 2, 3
– Haldol .5 mg  Haldol 0.5 mg
• Never use a terminal zero
– -Colchicine 1 mg not 1.0 mg
• Space between name and dose1,3
– Inderal40 mg  Inderal 40 mg

1. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-
8.23.
2. Jones EH. Clev Clin J Med 1997; 64: 355-9.
3. Cohen MR. Am Pharm 1992; NS32; 32-3.
Written Medication Orders: Drug Names

 “Look-Alike” or “Sound-Alike” Drug Names

 “Confirmation Bias”
 Addition of Suffixes
 Example Adalat CC 30 mg vs. Adalat 30 mg

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Cohen MR. Am Pharm 1992; NS32: 21-2.
Look-alike And Sound-alike Drug Names
Accupril® Accutane®
Alprazolam Lorazepam
Cardene® Cardura®
Flomax® Fosamax®
Lamisil® Lomotil®
Nizoral® Neoral®
Plendil® Prilosec®
Zantac® Zyrtec®

USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.

What is TALL man Lettering?

 It is an error-prevention strategy used as part of a mu

lti-faceted approach to reduce the risk of look-alike
and sound-alike medicine name confusion and error
s.
 It is a typographic technique that uses selective c
apitalisation to help make similar-looking medicine n
ames easier to differentiate.
 Its purpose is to help select or supply the right m
edicine.
How does it WORKS?

 Tall Man lettering combines lower- and u

pper-case letters to highlight the diff
erences between look-alike and sound-ali
ke medicine names, like fluOX
ETine and fluVOXAMine, making them e
asier for the eye to distinguish.
High-Alert Medications

 High-alert medications are drugs that bear a h

eightened risk of causing significant patient harm w
hen used in error
 Errors may not be more common with these than
with other medications, but the consequences of
errors may be devastating
 ISMP’s List of
High-Alert Medications
• Adrenergic agents • Insulin/hypoglycemics
• Anesthetics • Liposomal products
• Antiarrhythmics • Narcotics
• Anticoagulants • Neuromuscular blocking agents
• Cardioplegic solutions • Nitroprusside
• Chemotherapy • Oxytocin
• Dextrose ≥20% • Parenteral nutrition
• Dialysis solutions • Promethazine
• Electrolytes (concentrated) • Radiocontrast agents
• Epidural/intrathecal agents • Sedatives
• Epoprostenol • Sterile water for injection
• Inotropic agents

www.ismp.org/Tools/highalertmedications.pdf
Preventing High-alert Medication
Errors in Hospital Patients

 Performing Independent Double-checks

 Limiting Interruptions During Medication
Administration
 Reducing Confusion Around Drug Names
What Else Can You Do To Decrease Medication
Errors?
• Stop the line. If you have concerns or questions, do not give the
medication until you feel the concerns/questions have been answered.
• If a patient or caregiver questions the medication you are going to a
dminister: STOP! Double check the order and if necessary, call the pr
ovider to verify the order.
• If you have to pull 2 vials of a medication out of Omnicell or you have to d
raw up a large quantity of a medication: STOP! Recalculate with a peer. T
his is pediatrics! Medication doses are smaller than adults and are gi
ven in mg/kg!
• Tired? Distracted? Triple check yourself!
Medication Administration Documentation

• Documentation of medication dose, time, date, route must occur every

time a medication is administered, at the time of administration.
• If you give a scheduled med late you must document the actual time given
• If a scheduled med is not given you must document not given and, the
reason why.
 A true comedy of errors

• Attending MD tells the resident to give the patient

“free water” (meaning let her drink water”)
• Resident assumes he meant an IV and writes for
water to be given IV
• New RN can’t find IV water and calls pharmacy as
king where they get IVs; pharmacy asks no questi
ons and tells the RN they get them from C.S.
• RN obtains IV from C.S. never questioning RN w
hy she by-passed pharmacy; water bag says “wat
er for irrigation”
(continued)
A true comedy of errors

• RN attaches the bag to regular IV tubing; R

N infuses 600 mL of “free water”
• At change of shift, more experienced RN notes
patient is lethargic, sees bag of water, removes
it, and calls MD

Free water has no electrolytes and would

likely have caused burst red blood cells and
death if the second RN hadn’t interceded
What did staff do wrong ?
Should someone be fired ?

• MD #1: used an unfamiliar term “free water” wh

en he meant let the patient drink water
• MD #2: intimidated to clarify so he wrote what h
e assumed was supposed to be an IV
• RN: well-meaning, wanted to help her patient; s
he called pharmacy and talked to whoever ans
wered the phone; went to obtain the IV directly
from Central Stores Dept

(continued)
What did staff do wrong ?
Should someone be fired ?

• Pharmacy tech: didn’t identify herself as a te

ch; didn’t ask why the RN had this unusual re
quest; didn’t consider having pharmacist con
sult with RN
• C.S. staff: never questioned RN why pharma
cy was not involved; provided drug directly to
RN without normal pharmacy process
CALCULATION ERRORS

A patient needs 300 micrograms of a medication that

comes in a 1 ml ampoule containing 1 mg of the drug.
What volume do you draw up and inject?
EXAMPLE CASE
 a 74-year-old man sees a community doctor for treatment of new
onset stable angina
 the doctor has not met this patient before and takes a full past
history and medication history
 he discovers the patient has been healthy and only takes
medication for headaches
 the patient cannot recall the name of the headache medication
 the doctor assumes it is an analgesic that the patient takes when
ever he develops a headache
EXAMPLE CASE
 but the medication is actually a beta-blocker that he t
akes every day for migraine; this medication was p
rescribed by a different doctor
 the doctor commences the patient on aspirin and a
nother beta-blocker for the angina
 after commencing the new medication, the patient d
evelops bradycardia and postural hypotension
 unfortunately the patient has a fall three days later
due to dizziness on standing; he fractures his hip in
the fall
What Factors Contributed to this Medication Error?

 two drugs of the same class prescribed unknowingly with

potentiation of side-effects
 patient not well informed about his medications
 patient did not bring medication list with him when consulting
the doctor
 doctor did not do a thorough enough medication history
 two doctors prescribing for one patient
 patient may not have been warned of potential side-effects a
nd of what to do if side-effects occur
How could this situation have been prevented?

 patient education regarding:

 regular medication
 potential side-effects
 the importance of being actively involved in their
own care - e.g. having a medication list
 more thorough medication history
 REDUCING MEDICATION ERRORS

• Nurses:
 foster a commitment to patients’ rights
(YOU are the patient’s advocate)
 be prepared and confident in questioning m
edication orders
 participate in, or lead, evaluations of the e
fficacy of new safety systems and technology
 support a culture that values accurate
reporting of medication errors
Preventing Medication Errors: Quality Chasm Series. accessed 2010. www.nap.edu/catalog/11623.html.
 Always check patient’s identification bracelet
 Ask patient to state their name and birth date
 Compare medication order to identification
bracelet and patient’s stated name and birth
date.
 Verify patient’s allergies with chart and with
patient.
 Perform a triple check of the medication’s label
 When retrieving the medication.
 When preparing the medication.
 Before administering medication to patient.
 Always check the medication label with the
physician’s orders.
 Never administer medication prepared by another
person
 Never administer medication that is not labeled.
 Check label for medication concentration.
 Compare prepared dose with medication order.
 Triple all medication calculations.
 Check all medication calculations with another nurse.
 Verify that dosage is within appropriate dose range
for patient and medication.
 Verify schedule of medication with order;
 Date
 Time
 Specified period of time
 Check last dose of medication given to patient
 Administer medication within 30 minutes of schedule
 Verify medication route with medication
order before administering.
 Medication may only be administered
via route specified in order.
 Inform patient of medication being
administered
 Inform patient of desired effects medication
 Inform patient of side effects of medication
 Ask patient if they have any known allergies to
medication
 The legally responsible party (patient, parent, family
 member, guardian, etc.) for patient’s care has the right
 refuse any medication.
 Inform responsible party of consequences of refusing medication
 Verify that responsible party understands all of these
consequences.
 Notify physician that ordered medication and document
notification.
 Document refusal of medication and that responsible
 party understands consequences.
 Properly assess patient and tests to determine if medication
is safe and appropriate.
 If deemed unsafe or inappropriate, notify ordering
physician and document notification.
 Document that medication was not administered and the
reason that dose was skipped.
 Assess patient for any adverse side effects.
 Assess patient for effectiveness of
medication.
 Compare patient’s prior status with post
medication status.
 Document patient’s response to medication.
 Never document before medication is administered
 After an error that has harmed a patient has occurred, we often ask
the question: how did this happen?

 It can be very tempting to apportion blame to just one issue or person

or factor

 Medication errors can destroy lives, affect human relationships and

threaten trust in the healthcare system as a whole care
 Consider special needs of persons with disability
 Most persons we serve have severe oral motor problems
 Difficulty opening their mouth
 Tonic biting on a utensil
 Delayed swallowing or loss of food or fluid from their mouth
 Aspiration/Choking
References
 Medication Safety, Graham Bedford, Margaret Duguid
 Introduction To Medication Safety
 Medication Administration For Nursing Students In Clinical a
t Seattle Children’s Carol Shade, MS, RN, CPHIMS
 Adrian Harden, BSN, RN
 Leslie R. Harder, MN, RN-BC