Review On Medication Errors

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V.G.Kuchake

V.G.Kuchake

According to National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), Medication Errors is defined as,     “Any preventable event that may cause or leads to inappropriate medication use or patient harm while the medication is in the control of the Health care Professionals, Patients or consumers”.1

(OR)

“A medication error is defined as deviation from the prescribers order”. 2The American society of health systems pharmacists (ASHP) definition of medication errors includes, “Prescribing, Dispensing, Medications, Administration and patient Compliance errors.2.

Medication errors are serious problems through out the world. These errors have a huge economic impact on healthcare system, patients and payers alike. For example the cost of medication errors in the United States has been estimated to be nearly $ 30 billion per (2001) year and may be nearing $ 40 billion per year (2001) and the cost of these errors are counted more than just dollars. The medication errors and adverse drug events occur in all types of patients, in all type of setting; their proximal causes can be associated with physicians, pharmacists, nurses, caregivers or patients.3

Medication error rate is frequent, occurring at a rate of nearly 1 of every 5 doses in the typical hospital and skilled nursing facility. The percentage of errors rated potentially harmful was 7%, or more than 40 per day per 300 inpatients, on the average. 

A medication error is an episode associated with the use of medication that should be prevented through effective control systems. Pharmacists have a long-standing interest in improving medication safety and have studied the ways and means to reduce medication errors. The legal literature is replete with cases of injury or death caused by errors in the administration of medications and these unfortunate incidents are not restricted to occurrence within the hospitals, but also in doctor’s offices, clinics, retail pharmacies and in the home. All the incidents, which are related to medication error, are due to less awareness about the hospital policies. Because of the hospital pharmacists who are the best in assessing whether or not safe practices were being followed in handling, storage, administration or dispensing of drugs and related products. They must assume the mantle of responsibility for development of the required policies for adoption by the administration and hospital board of trustees.1

Types Of Errors

Prescription errors: -

These errors involved prescribing missing or inaccurate allergy information, improper or omitted dose, route of administration, improper or omitted frequency, medication omission, medication incorrect or unspecified medication, unauthorized drugs, duplication, missing or inaccurate patient weight, These errors are made by the busy treating clinicians. These errors, which lead to the administration of wrong dose, may sometimes. Be life-threatening misplacement of the decimal point while calculating the dose is a potentially fatal error. Inappropriate or inadequate instructions for use of a medication ordered by a physician or other authorized prescriber. 

Prescribing injections in milliliters instead of milligrams without mentioning the strength of injections is an error often made by the doctors. Prescribing syrups in teaspoons is another inaccurate way of prescribing because variable size of spoons may be used resulting in inadequate or excessive dose.5, 6

Dispensing errors:-

Dispensing is an integral part of the quality use of the medicines and together with the patient counseling from the core professional activities of a pharmacist. These activities allow the safe and efficient provision to the general public of what would normally be dangerous or restricted drugs. The squeal to serious is dispensing errors may be far-reaching, including patient morbidity and mortality, increased health expenditure due to hospitalization and treatment, and loss of credibility and professional standing for the pharmacist along with the risk of litigation and financial loss. Dispensing errors generally refers to errors in the dispensing process e.g. wrong drug or dose strength, incorrectly labeled directions or drug dispensed to wrong patient that are not detected and corrected prior to the patient leaving the pharmacy and which may be to sub optional outcome of treatment for the patients.7

Main risk factors associated with the Dispensing errors were found to be prescription overload, lighting levels, noise, interruptions and distractions. Also the major parts of the dispensing errors were related to wrong drug or wrong strength.7

Dispensing error originating from the point that medication was dispensed from the pharmacy. Dispensing errors includes incorrect admixtures of medications within the pharmacy and dispensed to the floor for administration of the dose.8, 5

Administration Errors:-

An error originating during the process directly associated with medication administration at the nursing unit.2,9

Monitoring errors:-

Failure to review a prescribed regimen for appropriateness, or failure to use appropriate clinical or laboratory data for adequate assessment of resident response to prescribed therapy. 

Potential errors:-

A mistake in prescribing, dispensing or planned medication administration that is detected and corrected through intervention before actual medication administration.

Compliance errors:-

Inappropriate resident behavior regarding adherence to a prescribed medication administration.

Clerical errors:-

These errors often arise on one hand due to the errors in copying out doctor’s instruction and on the other hand due to the mistaken identity of patient leading to the administration of unauthorized drug. The problem of mistaken identity can very seldom occur if two patients of the same name are kept in the same room. This can be easily avoided if extra precaution is taken to confirm the identity.5

Other Medication errors:-

Any error that does not fall in to a predefined category.5

Causes Of Medication Errors:-

The majority of medications errors are symptoms of poorly designed drug ordering and delivery systems 2, 10, 11. The improvement of this performance requires changing the systems, not the people, but also medication errors can occur for number of reasons, which includes;

  • Insufficient or inadequate information about the patient.
  • Lack of knowledge about drug therapy.
  • Poor communication of drug information
  • Poor hand writing.
  • Confusing or misleading drug labeling, packing and   nomenclature.
  • Poor drug storage and stocking.
  • Problems with standardization and distribution.
  • Poor safety assessment of drug delivery devices before Purchase and during their use.
  • Misinterpreted verbal orders.
  • Lack of time.

lesar had studied medication-prescribing errors in a teaching hospital for a one-year period. From the total number of 2, 89,411 medication orders, he found out a total of 905 prescription errors and the main reason for those medication errors includes; 2

Ø Over dose/under dose

Ø Missing information

Ø Wrong dosage from / wrong drug / wrong route out ordered

Ø Allergy to ordered drug

Ø Duplicate therapies and wrong Patient

How To Prevent Medication Errors

Because of the medication errors, the hospitalization of the patients are becoming higher and also because of the same, many more patients are seen in ambulatory settings such as Physicians offices, clinics, urgent care centers, nursing homes and home health services. The emergence of new technology offers greater potential to improve both the efficiency and accuracy of care, resulting in improved patient safety. The following applications of technologies can prevent medication errors. 2, 9

Computer Physician Orders Entry System (CPOE)

Computer Physician Orders Entry is a computer application that accepts the prescribers order for diagnostic and treatment services electronically rather than recording them in writing on an order sheet or prescription pad which includes orders against standards for dosing, check for allergies or interactions with other medications and warn the prescribers about potential problems. Hence by implementing, Computer Physician orders entry system can provide a term based intervention program that increase the availability, role of pharmacists and can reduce serious medication errors.

Bar Code Bed Side Care System

Bar Coding System is another recommended top-priority action for preventing adverse drug events in hospitals through a machine-readable coding e.g. Bar coding. It has been suggested that the checking and documentation function that occur when medications are administered. It could be done more effectively and accurately if aided by bar code scanning. A bar code drug administration system could linked to clinical information and the medication profile, so that when the dose is administered, an automatic check be made to assure the fact that the drug has prescribed for the patient, the dose, time and route of administration was correct and then the patient does not having an allergy to the medication have been given, etc.       

Scanners

For those pharmacies with scanners all medication bottle taken from shelf should be scan against the bar-code on the patient price sheet/ information sheet to make sure that it is the correct medication, before counting.

National Drug Code Numbers (NDC)

Those who work in pharmacies that do not have bar code scanners, the National drug code numbers along with the drug must first verify before counting begins. There are three segments for National drug code numbers. The first segment is labeler code, a label any firm that manufactures, repacks or distributes a drug product. The second segment the product code, which identifies a specific strength, dosage form and formulation for a particular firm. The third segment, package code that identifies the package sizes. By verifying all these conditions pharmacists can tell that where error occur and they can correct it suddenly.

Automated Dispensing

Hospital pharmacies increasingly using drug dispensing machines or robots. Some of these machines work like banking ATMs. Pre packed medications are dispensed instead of cash or postage stamps. Healthcare workers enter a user identification and password and swipe their ID cards through the machines electronic reader.

Also a new robotic drug dispensing are implemented and called as Rapid script, it cuts the prescription waiting time as well as improving accuracy when a pharmacist punches an order in to the Rapid script computer, the machine cuts the medication, fills vial is handled by robotic arms then prints and applies labels.

These systems decrease errors made by pharmacists. It does not eliminate errors that come either from physicians or errors that may occur while the pharmacist attempts to read and interpret the physician’s order etc.9

Other Methods To Reduce Medication Errors

Providers also can use simple non-technological procedures to easily cut the error rates. But patient involvement, which often is over looked, and a very powerful method to reduce medication errors. Pharmacists and physicians should counsel the patient to know what medications they are taking, what all the possible side effects, etc. Also patient should be encouraged to inform their doctor or pharmacist, about their treatment discrepancies and side effects very early. Early and frank conversation by patients with their healthcare can help to minimize the effects, if not help to prevent errors.

The following outlines are some of the recommendations developed by various Individuals and groups to assist in reducing of medication errors.

ØHospital-wide Actions and Policies to Decrease Medication Errors

  • Establish and maintain functional formulary system with policies for drug evaluation, selection, and therapeutic use.
  • Provide an adequate number of well-trained persons to prepare, dispense, and administer medications.
  • Provide a suitable work environment for safe, effective drug preparation.
  • Establish a clearly defined system for drug ordering, dispensing, and administration that includes review of the originaldrug order before dispensing and administration.
  • Provide ongoing formal quality improvement of the therapeutic use of medications including a drug-use evaluation (DUE) program.
  • Maintain medication profiles for both inpatients and ambulatory patients receiving care at the hospital.
  • Computerize systems, where possible, to check dose and dosage schedules, drug interactions, allergies, and duplicated therapies.

ØMedication Ordering to Reduce Errors

Physician prescriptions and drug orders are a means of communicating, so they must be legible, clear, and unambiguous. Thefollowing steps may help to ensure that medication orders communicatesafely and effectively.

  • Confirm that the patient's weight is correct for weight-based dosages.
  • Identify drug allergies in patients.
  • Write out instructions rather than using abbreviations.
  • Avoid vague instructions (e.g., take as directed; no order should be written without dose and volume where appropriate).
  • Specify exact dosage strength.
  • Avoid use of a terminal zero to the right of the decimal point (e.g., use 5 rather than 5.0) to minimize 10-fold dosing errors.
  • Use a zero to the left of a dose less than 1 (e.g., use 0.1 rather than .1) to avoid 10-fold dosing errors.
  • Avoid abbreviations of drug names (e.g., MS may mean morphine sulfate or magnesium sulfate).
  • Spell out dosage units rather than using abbreviations (e.g., milligram or microgram rather than mg or µg; units rather than u).
  • Ensure that prescriptions and signatures are legible, even if it means printing the prescriber’s name that corresponds to the signature.

ØPrescribers Actions to Decrease Medication Errors

  • Stay current concerning appropriate treatment of medical conditions they manage.
  • Review the patient's existing drug therapy before prescribing new medications.
  • Remain familiar with individual hospital medication ordering systems.
  • Ensure that drug orders are complete, clear, unambiguous, and legible.
  • Reserve verbal orders for instances when it is impossible or impractical to write an order or enter it in the computer.
  • When possible, speak with the patient or caregiver about the medication that is prescribed and any special precautions orobservations that should be noted, such as allergic or hypersensitivityreactions.
  • Clarify orders to "hold" medications and avoid these whenever possible.

ØPharmacy Actions to Decrease Medication Errors

  • Remain available to prescribers and nurses to participate in drug therapy development and monitoring.
  • Never guess or assume the intent of confusing medication orders.
  • Review an original copy of the written medication order before dispensing a medication, except in emergency situations.
  • Prepare drugs in a clean and orderly work area with a minimum of interruptions.
  • Dispense medication in a timely fashion using a unit-dose, ready-to-administer form whenever possible.
  • Provide counsel to patients or caregivers about their medications.

ØNurses Actions to Decrease Medication Errors

  • Be familiar with medication ordering and use system.
  • Verify drug orders before medication administration.
  • Confirm patient identity before administration of each dose.
  • Check medication calculations with a second individual.
  • Unusually large volumes or dosage units for a single patient dose should be verified.
  • When patient questions whether a drug should be administered, the nurse should listen, answer questions, and if appropriate,double-check the medication order.
  • Remain familiar with the operation of medication administration devices and the potential   for errors with such device.

ØPatients and Families

  • Communicate concerns and questions related to past or present   medication administration to providers, including any developmental or behavioral barriers to successful medication administration.
  • Inform physicians and hospital staff of any old or new allergy.
  • Inform physicians and hospital staff about a child’s use of complementary or alternative methods of health maintenance or therapeutic treatment, including herbal or dietary supplements.
  • Inform physicians and hospital staff about prescribed or over the counter medications the child is taking.
  • Be responsible for knowing the medication names, strength and dosing. Ensure that dosing interval followed as prscribed.Ask questions to ensure understanding of medication administration. When possible, bring all current medications to the hospital for confirmation and review.
  • Ensure that patient identity has been checked before medication administration.
  • Ask questions about the purpose of each medication to be use. 12, 13

ØAvoiding Medication Errors at Home

One to four percent of all visits to the emergency room are due to inappropriate use of medications that is no fault of the patient's. Counseling at the point of delivery in the pharmacy is an area in which pharmacists can significantly improve medication safety and patient compliance. Pharmacists can help patients avoid medication mishaps and latent errors at home by providing them with tips on medication safety. 1

  • Make a list of medications you are now taking. Include the dose, how often you take them, the imprint on each tablet or capsule, and the name of the pharmacy. The imprint can help you identify a drug when you get refills.
  • Any time your medications change, be sure to change your list, too.
  • Also list any medication allergies or food allergies you may have, and any over-the-counter medications, vitamins, nutritional supplements or herbal products that you take.
  • Keep medications in their original containers. Many pills look alike, so by keeping them in their original containers, you will know which is which and how to take them.
  • Read the label every time you take a dose to make sure you have the right drug and you are following the instructions.
  • Turn on the lights to take your medication, and, if needed, wear your eyeglasses. If you can't see what you're taking, you may take the wrong thing.
  • Do not store medications in the bathroom medicine cabinet or in direct sunlight. Humidity, heat, and light can affect medications' potency and safety.
  • Keep medications for people separate from pets' medications. Mix-ups can be dangerous.
  • Do not keep tubes of ointments or creams next to your tube of toothpaste. They feel a lot alike when you grab quickly, but a mistake could be serious.
  • Flush old medications down the toilet. Some drugs become toxic after the expiration date.
  • Do not chew, crush, or break any capsules or tablets unless you are told to do so by your pharmacist or your physician. Some long-acting medications are absorbed too quickly when chewed and other medications won't be effective or could make you sick.
  • To give liquid medication, use only the cup or measuring device that came with it. Dosing errors can happen if you use a different cup, because the cups are often different sizes or have different markings. Also, household teaspoons and tablespoons are not very accurate, which is important with some medications. Your pharmacist may give you a special spoon or syringe instead.

Key Elements Of Medication Use System.

Medication use is a complex process that comprises the sub-processes of medication prescribing, order processing, dispensing, administration, and effects monitoring. The key elements that most often affect the medication use process, and the common failures and medication errors associated with them are listed below. The interrelationships among these key elements form the structure within which medications are used 15.

1.  Patient information: Obtaining the patient’s pertinent demographic and clinical information that will assist practitioners in selecting the appropriate medications, doses and routes of administration. Having essential patient information at the time of medication prescribing, dispensing and administration will result in a significant decrease in preventable adverse drug events.

2.   Drug information: Providing accurate and usable drug information to all health professionals involved in the medication use process reduces the amount of preventable ADEs. Not only should drug information be readily accessible to the staff through a multitude of sources (drug references, formulary, protocols, dosing scales…), it is imperative that the drug information is up to date as well as accurate.

3.  Communication of drug information: Miscommunication between physicians, pharmacists and nurses is a common cause of medication errors. To minimize the amount of medication errors caused by miscommunication it is always important to verify drug information and eliminate communication barriers.

4.  Drug labeling, packaging and nomenclature: Drug names that look-alike, sound-alike, have confusing drug labeling and non-distinct drug packaging significantly contribute to medication errors. The incidence of medication errors is reduced with the use of proper labeling and the use of unit dose systems within hospitals.

5.  Drug storage, stock and standardization: Standardizing drug administration times, drug concentrations and limiting the dose concentration of drugs available in patient care areas will reduce the risk of medication errors or minimize their consequences should an error occur.

6.  Drug device acquisition, use and monitoring: Appropriate safety assessment of drug delivery devices should be made both prior to their purchase and during their use. Also, a system of independent double-checks should be used within the institution to prevent device related errors such as, selecting the wrong drug or drug concentration, setting the rate improperly, or mixing the infusion line up with another.

7.  Environmental factors: Having a well-designed system offers the best chance of preventing errors; however, sometimes the environment in which we work contributes to medication errors. Environmental factors that often contribute to medications errors include poor lighting, noise, interruptions and a significant workload.

8.  Competency and staff education: Staff education should focus on priority topics, such as: new medications being used in the hospital, high- alert medications, medication errors that have occurred both internally and externally, protocols, policies and procedures related to medication use. Staff education can be an important error preventions strategy when combined with the other key elements for medication safety.

9.  Patient education: Patients must receive ongoing education from physicians, pharmacists and the nursing staff about the brand and generic names of medications they are receiving, their indications, usual and actual doses, expected and possible adverse effects, drug or food interactions, and how to protect themselves from errors. Patients can play a vital role in preventing medication errors when they have been encouraged to ask questions and seek answers about their medications before drugs are dispensed at a pharmacy or administered in a hospital.

10.  Quality processes and risk management: The way to prevent errors is to redesign the systems and processes that lead to errors rather than focus on correcting the individuals who make errors. Effective strategies for reducing errors include making it difficult for staff to make an error and promoting the detection and correction of errors before they reach a patient and cause harm.

Role Of Pharmacists In Medication Errors Reduction

Medication errors can occur at any time. The reports of medication errors and interventions should be evaluated and incorporated in to Continuous Quality Improvement program (CQI). The pharmacist must assume responsibility for developing and implementing a plan for the prevention of medication errors through detection and evaluation. The following guidelines will help the pharmacist for the same. 16

Assessment

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Examine and evaluate the cause of medication errors and analysis of aggregated data to determine trends, significances, frequency and outcomes.

Ø  Evaluate the medication use process in collaboration with other healthcare professionals.

Ø  Establish a process for identifying and tracking medication errors

Ø  Define categories of medication errors, e.g. prescribing, dispensing, administration, monitoring, compliance errors, etc.

Ø  Simplify process for documenting errors by developing a medication error reporting and evaluate form.

Prevention

Increase awareness of medication error through educating about the importance of all medication errors, regardless of their suspected significance.

Ø  Establish systems for detecting medication error in the facility and pharmacy, e.g. observation, random sampling, and medication storage survey etc.

Ø  Involve healthcare practitioners, patients and care givers in the medication error detection and reporting process.

Reporting

Ø  Deemphasize the focus on the punitive aspects to encourage medication error reporting and focus on the improvement of process and systems.

Ø  Respect the confidentiality of patient, facility and personnel involved in the medication errors

Pharmacists should lead efforts to examine where errors arise in the drug use system. This can be accomplished by establishing a quality assurance program that regularly examines all aspects of the drug use system and also produce information required to identify problems and allow for appropriate changes.17

Pharmacists, pharmacy technicians, and other health care professionals involved in the medication use process must work together to develop a systems approach to medication error reduction.17

The interruptions to the pharmacist should be reduced as they break up the attention on the prescription at hand. Distraction by non – professional activities was potentially dangerous and this should not occur. Interruptions can be reduced by providing a comfortable waiting area and providing pharmacist support personnel’s (Technician or Assistant). The difficulty that community pharmacies had in separating commercial and patient care interest may also cited as a major reasons for incomplete professionalism. The overall medium response to reduce the Medication errors like, having mechanism for checking dispensing procedures, systematic dispensing workflow, checking original prescriptions, keeping knowledge of the drugs up to date etc. The above discussion suggests that Quality assurance procedures are important in avoiding Medication errors. In order to reduce the occurrence, methods must be devised to identify the errors and implement strategy to correct them. Standards in the dispensing process must set appropriately high were a zero error tolerance within the profession should prevail because consumers have zero error expectation.

Bibliography

1.  Mukesh Chandra Joshi, Vijay Roy, Medication Errors: identification, prevention and implementation of safe medication practice, IJHP, March 2005.page No.62.

2.  G.Parthsarathi, A text book of clinical pharmacy practice. Essential elements and skills.2004.page No.426.

3.  Linda L.Norton: Quality improvement, risk management, and patient education: Tools to reduce medication errors. J of Managed Care Pharmacy (JMCP), March 2001.Vol.7.No.2, Page no 156.

4.  Kenneth N. Barker, Elizabeth A,Ginett A, David W Bakes, Robert L,Mikeal:Medication errors observed in 36 health care facilities. Arch Intern Med / Vol 162, Sep 9, 2002.Page no 1897. (www.Archinternmed.com).

5.  M.C.Bindal, M.Sharma, A.Tilak: Combating errors in medication for children-  The pharmacists Role.IJHP, May-June 2000.Vol 37.No 3.

6.  Anne Bobb, Kristine Gleason, Marla Husch, Joe Feinglass, Paul R, Gary A: The epidemiology of prescribing errors. Arch Intern Med. April 2004; vol 164:No12, Page No.785-792.

7.  Peterson GM, WU MS, Bergin Jk; Pharmacists attitudes towards dispensing errors:  there causes and prevention.Clin Pharm Ther, 1999 Feb; 24 (1):57-71.

8.  Bond CA, Raehl Cl; Pharmacists assessment of dispensing errors: Risk factors, practice sites, professional functions, & Satisfaction. Pharmacotherapy, 2001 May; 21(5):614-626.

9.  Medication errors: Available on www.saferhealthcare.com, Institute of Medicine:http://www.iom.edu and Medication errors: http://www. mederrors.com.

10.  Vijay Roy, Puneet Gupta, Shouryadeep Srivastava; Medication errors: Causes and prevention. The Pharma Riview, Aug 2005; 37-40.

11.  P.M.K.Reddy, Steven A.Dkhar, G Nartunai, D.G.Shevade: Prescription handling errors, IJHP Jan-Feb.2001; Vol, 38:27-30.

12.  Prevention of medication errors-in the Pediatritics inpatient setting. Pediatrics, Aug 1998; vol 102. No (2); page No.428-430.

13.  Grove Village: Prevention of medication errors in the pediatrics inpatient setting. Pediatrics Aug 2003; Vol, 112 No (2); page No.431-436.

14.  K.Mandal, SG, Fraser: The incidence of prescribing errors in an eye hospital: BMC optholmology.march 2005, 5:4 and also available on  http://www.biomedcentral.com.

15.  Huntingdon Vally: Frequently asked questions.2005; available on http://www.ismp.com.

16.  Understanding and preventing medication errors, U.S.Pharmacopeia.

17.  David M.Banjamin: Reducing medication errors and increasing  patient safety; The J Clin Pharmacol, 2003; 43:767-783.

About Authors:

V.G.Kuchake

V.G.Kuchake
R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.)
For Correspondence:
Lecturer, Department of Clinical Pharmacy, R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.), India.
Email- vitthalkuchake@yahoo.co.in: Phone- +91 9421750308

 P.V.Ingle

P.V.Ingle
R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.)

P.H.Patil

P.H.Patil
R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.)

C.R.Patil

C.R.Patil
R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.)

A.R.Tekade

A.R.Tekade
R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.)

M.P.Ratnaparakhi

M.P.Ratnaparakhi
Marathwada Mitra Mandal’s College of Pharmacy, Kalewadi, Pune.

S.J.Surana

S.J.Surana
R.C.Patel College of Pharmacy, Shirpur, Dist: Dhule (M.S.)

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