Medication Safety and Error

Prevention
Chapter 14

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 Lesson 14.1

Medication Safety and Error Prevention

1. List the five patient rights and give an example

of each.
2. Describe what constitutes an error.
3. Differentiate between the various types of
medication errors.
4. Explain the various causes of medication errors.
5. Explain the necessity of reporting medication
errors.
6. List the organizations or groups that track and
report medication errors.
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 Lesson 14.1

Medication Safety and Error Prevention

7. Identify safety strategies pharmacies,

pharmacists, and pharmacy technicians can
use to reduce medication errors.
8. List and describe four automated systems
and explain how they prevent errors.
9. Explain how electronic prescribing is used to
reduce errors.
10. Describe the role training and education
plays in the reduction of medication errors.
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 Five Rights of Medication Safety

 The right patient: Always verify patient

identification information
 The right medication: Be sure it's exactly what
the physician ordered
 The right dose: Verify number of
doses/tablets to be taken daily
 The right route: Find the one that works best
for the patient
 The right time: Give medications at the right
time of day

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 What Constitutes an Error?

 There are three main categories of errors:

 Prescribing errors
 Dispensing errors
 Administration errors

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 Types of Medication Errors

 Prescribing errors
 Incorrect strength, no refill information, illegible
handwriting
 Sound-alike/look-alike errors: Incorrect
interpretation, incorrect calculations, incorrect
drug utilization evaluation (DUE)
 Administration errors: Ear medications being
placed in eye, incorrect route of
administration, failure to accurately document

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 Where Errors Are Made

 Hospitals
 Clinics
 Pharmacies
 Physicians' offices
 Patient homes

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 Why Errors Occur

 Stress: Increased demand for services can

lead to more error occurrence
 Noise: Causes distractions, which affect
concentration
 Look-alike/sound-alike drugs: Food and Drug
Administration (FDA) reviews all drug names
 Labeling: Use color coding, Tall Man lettering,
and boldface
 Excessive workload: Hundreds of
prescriptions daily; no time for breaks

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 Drug Interactions as a Source of
Error and Warfarin Interactions
 Probability of drug interactions increased in
seniors or severely ill patients
 Taking similar drugs that have the same side
effects may increase the risk and/or the
severity of adverse effects
 Warfarin
 Given to prevent clots that can cause strokes or
heart attacks
 Avoid aspirin, phenytoin, quinolones, sulfa drugs,
cimetidine, heparin, amiodarone, nonsteroidal
anti-inflammatory drugs (NSAIDs)

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 Errors in the Pharmacy

 Open error reporting without fear of retaliation

is essential
 Identify the causes of the error and set
safeguards in place that will not allow the
error to happen again
 Report errors to MedWatch, The Joint
Commission, Institute for Safe Medication
Practices (ISMP), Medication Error Reporting
Program (MERP)

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 Errors Related to Patient Care

 Health care–associated infections (HAIs)

 Infections related to hospital care
 Home health care errors
 Improper dosing and IV use causes infections

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 Age-Related Errors and Allergy
Errors
 Pediatric patients
 New labels to prevent errors
 Incorrect dosing
 Errors involving allergies
 Failure to document/review patient's allergies
 Excessive workload

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 Parenteral Errors

 These errors take effect quickly and may not

be easily reversed
 It is common to flush IV lines with Hep-Lock
solutions, which may be confused with the
similarly sized and labeled vials of much
more concentrated heparin solutions

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 Sustained-Released (SR) Dosage
Form Errors
 If an SR medication is given in place of a
regular dose, adverse effects can occur,
which could include death
 Many of the errors occur due to suffixes on
drug products that are not clearly understood
 See LA, CR, CD, ER, XL and SR

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 Necessity of Reporting Errors

 Pharmacist's daily routine

 Workday includes filling prescriptions, addressing
order discrepancies, counseling patients, and
checking technician work
 Computerized prescription order entry
(CPOE)
 Electronic ordering saves time and frustration

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 e-Prescribing

 Prescriptions sent from computer or mobile

device directly to pharmacy
 This method is encouraged by insurance
companies
 There are many systems to choose from
when using this method

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 Reporting Errors

 Errors won't be reported if person will be

reprimanded
 "Being more careful" does not provide tools
for future error reduction
 Focus on reducing errors, not why errors
occurred
 Constructive changes can be tracked

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 Organizations That Track Errors

 FDA and Centers for Disease Control and

Prevention (CDC)
 FDA Medwatch
 FDA Adverse Event Reporting System
 Institute of Medicine (IOM)
 Institute of Safe Medication Practices (ISMP)
 National Coordinating Council for Medication
Error Reporting and Prevention (NCCMERP)

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 Strategies to Reduce Medication
Errors
 Dispense vinca alkaloids in minibags instead of
syringes
 Use a weekly dosage regimen
 Provide patient education from a pharmacist
 Measure and express patient weights in metric
units
 Ensure all oral medications not in unit dose are
taken with oral syringe
 Purchase oral dosing devices that only show
metric scale
 Eliminate glacial acetic acid from all areas of the
hospital
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 Bar Coding

 When a nurse is about to give a dose, he or

she scans the barcode of the patient’s
wristband against the barcode of the
medication
 Alarm goes off if there is a discrepancy
 Identification provided
 National Drug Code number
 Lot number and expiration date of the drug

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 Robot Rx Machines

 Medication records are read by the machine

by bar coding
 Appropriate medication’s bar code is read
from the package and matched to the
electronic medication administration record
(e-MAR)
 Machine will pull from a rack of pre-packed
unit dose medications

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 Automatic Dispensing Systems
(ADS)
 Hold unit-dosed medications and nursing
supplies to be accessed by nurses on the
patient floors
 Work effectively if the medication within the
drawer is correct
 If the wrong medication is loaded into the drawer
and the nurse fails to catch the mistake, then an
error can occur

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 Community Pharmacy ADS
Machines
 Three types of robotics:
 Table-top automatic pill counters: Model KL20 by
Kirby Lester
 Large wall units that use cassettes: Baker Cell
systems
 Robot technology: SP 200 System by Script Pro

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 Patient Dose-Specific Orders

 The Joint Commission requires hospitals and

institutions to prepack all liquid doses in oral
syringes
 Each dose is prepared by the technician and
is labeled with the patient’s name, medical
record, and room number
 The name of the drug, dose, strength and
time of administration is indicated on each
dose

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 USP <797> Regulations

 Addresses the problem of contamination of

any type of sterile product
 Many pharmacies are contracting their sterile
preparations out to companies that specialize
and have met all guidelines of USP <797>
 Error reduction:
 Check prescriptions thoroughly and initial them
 Document clarifications on orders

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 Medication Reconciliation

 This is the process of identifying the most up-

to-date list of all the medications a patient is
currently taking
 Verification, clarification, reconciliation
 Goal is to make sure the patient is being
given the proper medications at all times

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 Training and Education

 Certification and continuing education are

important
 Technicians should always check each
prescription three times throughout the filling
process
 Never be afraid to ask questions
 ASHP curriculum for pharmacy technician
training

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Questions?

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