Chapter Topics Medical errors Medication errors Prescription filling process in community and hospital pharmacy practices Medication error prevention Medication error reporting systems Learning Objectives ID: 734787
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Slide1
Safety
Medication errorsSlide2
Chapter TopicsMedical errors
Medication errors
Prescription filling process in community and hospital pharmacy practices
Medication error prevention
Medication error reporting systemsSlide3
Learning Objectives
Understand the extent of medical and medication errors and their effects on patient health and safety.
Identify specific categories of medication errors.
Discuss examples of medication errors commonly seen in pharmacy practice settings.
Apply a systematic evaluation to search for medication error potential to a pharmacy practice model.
Define strategies, including the use of automation, for preventing medication errors.
Identify the common systems available for reporting medication errors.Slide4
Medical Errors
Definition
Any circumstance, action, inaction or decision related to health care that contributes to an unintended health result
Examples
Lab test drawn at the wrong time that returns an inaccurate result
Infection resulting from improper technique
Major surgical error that results in deathSlide5
Medical Errors (continued)
Scope and impact
98,000 deaths in the United States per year due to medical errors in hospitals
Medical errors are the sixth leading cause of death in the United States.
Government and private insurers no longer reimburse hospitals for additional costs associated with medial errors.
Hospitals cannot bill patient for costs associated with medical errorsSlide6
Medication Errors
Definition
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
Includes prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and useSlide7
Medication Errors (continued)
Scope and impact
Drug errors in U.S. hospitals cause 400,000 preventable injuries per year.
In the United States, 7,000 deaths occur each year due to medication errors in hospitals.
About 1.7% of prescriptions dispensed in a community practice setting contain a medication error.
About $3.5 billion per year is spent on direct and indirect costs of medication errors.
Additional hospitalizations
Long-term care
Physician visits
Emergency room visitsSlide8
Medication Errors (continued)
Patient response
Physiological causes of medication errors
Increased susceptibility to medications
Absence of enzyme that removes medication from the body
Poor kidney function
Young patients (under 6 years old)
Elderly patients (over 66 years old)
Social causes of medication errors
Failure to follow directions
Misunderstanding directions
NoncomplianceSlide9
Medication Errors (continued)
Categories of medication errors
Classic Examples of Medication Errors
Error
Definition
Omission error
A prescribed dose is due, but not administered.
Wrong dose error
A dose
is either above or below the correct amount by more than 5%.
Extra dose error
A patient
receives more doses than were prescribed.
Wrong dosage form error
The dose formulation given is not the accepted interpretation of the physician’s order.
Wrong time error
Any drug given 30 minutes or more before or after directed is considered a wrong time error.Slide10
Medication Errors (continued)
Categories of medication errors
Classes
of Failure for M
edication Errors
Error
Cause
Example
Human
failure
Occurs at an individual level
Pulling a medication bottle from the shelf based on memory without checking
labels
Technical failure
Results from equipment problems
Incorrect reconstitution of a medication because of a malfunction of a sterile-water dispenser
Organizational failure
Results
from a deficiency in organizational rules, policies, or procedures
Policy requiring the preparing of chemotherapy
in an inappropriate settingSlide11
Medication Errors (continued)
Root-cause analysis of medication errors
A logical and systematic process used to help identify what, how, and why something happened to prevent recurrenceSlide12
Medication Errors (continued)
Root-cause analysis of medication errors
Root-cause
Analysis of Medication E
rrors
Error
Cause
Example
Assumption error
An
essential piece of information cannot be verified and an assumption is made.
A prescription
contains an illegible
abbreviation, drug name, or directions and is misread.
Selection error
Two
or more options exist and the wrong one is chosen.
A look-alike or sound-alike
drug is filled instead of the prescribed drug.
Capture error
Focus on a task
is diverted elsewhere.
The wrong number of tablets are dispensed while taking a phone call in the
middle of filling a prescription.Slide13
Prescription-Filling Process Slide14
Prescription-Filling Process (continued)
Each step in the filling process broken into parts
Information that needs to be obtained or checked
Resources that can be used to verify information
Potential medication errors that would result from a failure to obtain or check the necessary information
Each person who participates in the filling process has the opportunity to catch and correct a medication error.Slide15
Prescription-Filling Process (continued)
Step 1: Receive and review prescription
Basic review of prescription
Verbal order precautions
Clarify the order before moving to next step.
Ask the caller to read back the order.
Validity of prescription
Determine whether the prescription is legal and valid.
Look at the date and signature.
Outdated prescriptions should not be filled. Slide16
Prescription-Filling Process (continued)
Step 1: Receive and review prescription
Detailed review of prescription
Prescriber information
Determine whether a licensed and qualified prescriber wrote the prescription.
Look for the signature and contact information.
Patient information
Check enough details to pinpoint a unique individual.
Full names, addresses, dates of birth, and phone numbers are standard identifiers.
Date of birth and allergies help determine appropriateness of medication.
A prescriber’s signature is required for a written prescription to be considered valid.Slide17
Prescription-Filling Process (continued)
Step 1: Receive and review prescription
Detailed review of prescription
Medication information
Drug name, strength, dose, dosage form, route of administration, refills or length of therapy, directions, and dosing schedule
Prescribing errors
Poor handwriting, nonstandard abbreviations, sound-alike and look-alike drug names, and “as directed”
Incorrect notation of numbers
Abbreviations
qd
,
qid
, and
qod
A leading zero should precede values less than one, but no zero should follow a decimal if the value is a whole number. Slide18
In the Know: True or False
Medication errors are the 25
th
leading cause of death in the United States.
false
Costs associated with medication errors include emergency room visits.
true
A wrong dosage form error occurs when the incorrect strength of a medication is dispensed.
false
A prescriber’s signature is required in order for a written prescription to be considered valid.
trueSlide19
Prescription-Filling Process (continued)
Step 2: Enter prescription into the computer
Accurate data entry
As each piece of information is entered, compare the choices from the computer menu with the prescription.
Drug names, dosages, formulations, concentrations, and increments of measure Slide20
Prescription-Filling Process (continued)
Step 2: Enter prescription into computer
Potential dangers
Teaspoons vs. milliliters
Potential for five-fold error
Milliliters recommended for computer entry and labeling to minimize errors
Formulation mix-ups
Concentration mix-ups
Ointments vs. creams
Solutions vs. suspensions
Precautions with scheduled drugs
Immediate release vs. sustained release
oxycodone
productsSlide21
Prescription-Filling Process (continued)
Step 3: Perform drug utilization review and resolve medication issues
Drug utilization review (DUR)
Dosing ranges and drug interactions
Pharmacist should perform a DUR for dosing ranges, drug interactions, or duplication of therapy.
Particular care is warranted for pediatric, elderly, and pregnant patients.
Allergy-related alerts
Computer system flags allergies which should be brought to the attention of the pharmacist.Slide22
Prescription-Filling Process (continued)
Step 3: Perform drug utilization review and resolve medication issues
Drug utilization review (DUR)
Pharmacist follow-up
The pharmacist must decide whether to counsel the patient or contact the prescribing physician prior to approving the prescription.
Check the patient profile for existing allergies or possible drug interactions.Slide23
Prescription-Filling Process (continued)
Step 4: Generate prescription label
Cross-check the label output from the printer with the original prescription.
Patient name
Drug
Dose
Concentration
Route Slide24
Prescription-Filling Process (continued)
Step 5: Retrieve medication
Safe practices for accurate drug selection
NDC numbers
Cross-check
NDC number
Specific
to a particular form, package, and
strength
Specific NDCs for drug forms
Even at same strengthSlide25
Prescription-Filling Process (continued)
Step 5: Retrieve medication
Safety practices for accurate drug selection
Heparin safeguards
Serious medication errors have occurred when an incorrect heparin concentration was used.
Additional computer alerts, nurse-check-nurse systems, and limited availability of certain concentrations on nursing units help avoid Heparin errors.
Look-alike and sound-alike labels
Computer-based pill identification programs facilitate visual comparison of the medication dispensed. Slide26
Prescription-Filling Process (continued)
Step 6: Compound or fill prescription
Safety practices for accurate compounding and filling
Equipment maintenance
Equipment used should be maintained, cleaned, and calibrated regularly.
Check the accuracy of technology.
Auxiliary labels
Most computerized systems generate them at the same time as the medication label.
Patients are reminded of the most crucial aspects of proper medication administration.
They should always be included with prescription labeling.Slide27
Prescription-Filling Process (continued)
Step 7: Obtain a pharmacist review and approval
Responsibilities of the pharmacist
Verify the initial computer entry.
Check the quality and integrity of the end product.
Compare the label to the stock bottle and the
prescription.
The
stock bottle should accompany the labeled medication container and original prescription.
Role of the technician in the verification process
To develop an awareness of what is needed by a pharmacist, practice checking a colleague’s work.
The pharmacist must always check the technician’s work. Slide28
Prescription-Filling Process (continued)
Step 8: Store completed prescription
Proper storage conditions
Some drugs are sensitive to light, humidity, or temperature.
Improper storage may result in loss of drug potency or effect.
Refrigerator and freezer temperatures must be monitored and documented.
Orderly storage decreases the chances of one patient’s medications getting mixed up with another’s.Slide29
Prescription-Filling Process (continued)
Step 9: Deliver medication to patient
Verification of patient identity
Confirm the patient’s date of birth or address rather than just his or her name.
Explanation of medication to patient
Double-check the number of medications the patient expects to receive.
Inquire as to the patient’s knowledge of their proper use.
Consult the pharmacist if the patient has questions. Slide30
Prescription-Filling Process (continued)
Step 9: Deliver medication to patient
“Show and Tell” technique with patient
Open the vial and show the drug product to the patient.
Take the opportunity to double check that the correct drug was put into the vial.
Have the patient point out if refilled drug looks different from a previously filled drug. Slide31
Prescription-Filling Process (continued)
Step 9: Deliver medication to patient
“Show and Tell” technique with patient
ISMP’s “Tell-Back” system
Uses patient-centered, open-ended questions to help determine patient understanding
Pharmacy technicians cannot instruct patients about their medications. If a technician suspects that a patient requires instruction, then the technician should alert the pharmacist.Slide32
In the Know: True or False
When the computer provides an allergy alert, the technician should bypass the alert and fill the prescription.
false
The NDC number is an excellent mechanism for checking if the correct product is selected.
true
The medication dose is provided on the auxiliary labels.
false
When delivering a medication to a patient, verifying his or her first and last names is sufficient.
falseSlide33
Medication Error Prevention
Role of the pharmacy technician
Opportunities to identify errors throughout process
I
nteracting with nurse or patient
Receiving and examining the prescription
Entering data into the computer
Submitting prescription for filling
G
iving the medication to the patient
Incorrect drug identification is the most common error in dispensing or administration. Slide34
Medication Error Prevention (continued)Slide35
Medication Error Prevention (continued)
The responsibility of healthcare professionals
A commitment to “first do no harm”
Put safety first.
Pharmacy exists to safeguard the health of the public.
Focus on treating the patient and ensure the best possible outcomes by the safest means.
The only acceptable number of medication errors is
zero
. Slide36
Medication Error Prevention (continued)
The responsibility of healthcare professionals
Avoiding potential sources of errors
Technicians should listen and observe carefully during patient or medical staff interactions.
Technicians who assume more routine dispensing tasks allow the pharmacist more time for counseling and taking more detailed, accurate medical histories.
If information is missing from a prescription or medication order, a pharmacy technician must obtain the information from the prescriber. The technician should never make conjectures regarding missing content. Slide37
Medication Error Prevention (continued)
Patient education
Pharmacy technician’s role
Encourage patients to ask questions, provide complete medical and allergy history, and check medication labels.
Actively monitor for potential errors or patient misunderstandings.
Encourage patients to be informed about their conditions.
Encourage patients to ask the pharmacist questions.
Add information to patient profiles about prescriptions filled at other pharmacies or mail order.
Encourage patients to call the pharmacist if questions arise after leaving the pharmacy. Slide38
Medication Error Prevention (continued)
Patient education
Information Patients
Must Know about Their Medications
1. Brand and
generic names
2.
The medication’s appearance
3. The purpose of the medication, and the duration of treatment
4. The correct
dosage and frequency, and the best time or circumstances to take a dose
5. How to proceed if they miss a dose
6. Medications or foods that interact with
the prescribed medication
7. Whether the prescription is in addition to or replaces a current medication
8. Common side effects and how
to handle them
9. Special precautions
necessary for each particular drug therapy
10. Proper storage for the medicationSlide39
Medication Error Prevention (continued)
Innovations to promote safety
E-prescribing
Preprinted prescriptions
Drug, dose, schedule, frequency, amount dispensed can be circled
Minimizes transcription or illegible prescription errors
Common with specialists who prescribe a limited number of drugs
Use of automation
E-prescribing
eliminates the
problem of
illegible prescriptions or
soundalike
medications causing
a preventable
error
.Slide40
Medication Error Prevention (continued)
Innovations to promote safety
Workplace ergonomics
Workplace Ergonomic Practices to Promote Safety
1. Automate and bar code all procedures.
2.
Maintain a clean, organized, and well-lit work area.
3. Provide adequate storage areas with clear drug labels on the shelves.
4. Encourage prescribers to employ common terminology and only use safe abbreviations.
5. Provide adequate computer applications and hardware.Slide41
Medication Error Prevention (continued)
Innovations to promote safety
Package, medication, and label design
Package design
Clear labeling, large font size, easy-to-use dispenser, label
Target’s
ClearRx
design
Designed
to help patients
manage their medications
Information clear
,
easy-to-read formatSlide42
Medication Error Prevention (continued)
Innovations to promote safety
Package, medication, and label design
Medication design
Formulations with unique colors, shapes, or markings
Markings on tablet or capsule that verify the dose
Different colors for different doses of the same medication
Capsule identification on the stock bottle
Middle four numbers of the NDC in larger font or boldface typeSlide43
Medication Error Prevention (continued)
Innovations to promote safety
Package, medication, and label design
Label design
“tall man” or enhanced lettering
Warning statements on stock labels of high-risk medicationsSlide44
Medication Error Prevention (continued)
Innovations to promote safety
Use of automation
Bar-coding technology
Prescription entered into computer and verified
Stock bottle selected
NDC number of stock bottle scanned
Computer compares scanned bar code against prescription
Error message if no matchSlide45
Medication Error Prevention (continued)
Innovations to promote safety
Use of automation
Bar-coding technology
Automated
dispensing cabinets are maintained
primarily by
pharmacy
technicians.
Robot-based
medication dispensing
increases efficiency and speed of medication delivery without compromising safety.
The robot uses
bar codes
to validate drugs,
significantly reducing
the chances
of drug selection errors.Slide46
Medication Error Prevention (continued)
Innovations to promote safety
Use of integrated, automated systemSlide47
Medication Error Prevention (continued)
Innovations to promote safety
Use of integrated, automated systemSlide48
Medication Error Prevention (continued)
Professional prevention strategies
ASHP’s Pharmacy Technician Initiative
Enhances education and training of pharmacy technicians
Improves patient safety
Minimizes medication errorsSlide49
Medication Error Prevention
(continued)
Personal prevention strategies
Lifestyle recommendations
Get enough sleep.
Exercise regularly.
Take breaks at work.
Be wise about food.
Avoid excessive alcohol.
Cut the caffeine.
Even when things are busy, take breaks to relax and
revitalize yourself
, even if it means going outside to clear your head for a couple of
minutes. You
will not be much help if you cannot think clearly.Slide50
In the Know: True or False
A pharmacy technician can help detect errors by carefully listening and observing during patient interactions.
true
One of the recommended pieces of information patients must know about their medications is the cost.
false
“Tall man” or enhanced lettering is an example of an innovation to promote patient safety.
true
A personal prevention strategy in preventing medication errors is to listen to a headset while at work.
falseSlide51
Medication Error
Reporting Systems
State Boards of Pharmacy
Overview:
Some states have mandatory error-reporting systems.
Boards of Pharmacy do not punish pharmacists for errors, as long as a good-faith effort was made to fill the prescription correctly.
Some states regulate, require, or recommend a continuous quality improvement (CQI) program to detect, document, and assess medication errors.
Some states have proposed new laws that protect error reports from subpoena.Slide52
Medication Error
Reporting Systems
(continued)
State Boards of Pharmacy
Error reporting
Telling the Patient
Telling the Physician
The pharmacist is typically the one to report a medication error.
The
physician must be contacted if the error
will lead to a side effect.
Circumstances leading to the
error should be explained completely and honestly.
The prescriber must be notified if the error will cause an adverse drug reaction.
Patients should understand the nature of the error, what effects the error may have, how he or she can actively
prevent errors in the future.
The physician must be told if the error will impact the disease
being treated.Slide53
Medication Error
Reporting Systems
(continued)
Joint Commission’s Sentinel Event PolicySlide54
Medication Error
Reporting Systems
(continued)
Joint Commission
Accreditation and medication safety
Joint Commission supports the ISMP recommendations
Elimination of certain abbreviations
Education regarding frequently confused drug names
May recommend a safety program to improve communications in the ordering, preparation, and dispensing of medications
Standards recommend that hospital outline its responsibility in advising a patient about adverse outcomes of error.Slide55
Medication Error
Reporting Systems
(continued)
Joint Commission’s SPEAK UP CampaignSlide56
Medication Error
Reporting Systems
(continued)
United States Pharmacopeia
MEDMARX reporting system
Internet –based system
Allows healthcare professionals to anonymously document, analyze, and track adverse events
Most recent report shows that more than 60% of medication errors occur during dispensing, technicians involved in 38.5% of them.
Major contributing factors to medication errors include distraction in the workplace, excessive workload, inexperience.Slide57
Medication Error
Reporting Systems
(continued)
Institute for Safe Medication Practices (ISMP)
Overview:
A nonprofit healthcare agency
Membership comprised of physicians, pharmacists, and nurses
Mission
To understand the causes of medication errors
To provide and communicate error-reduction strategies to the healthcare community, policymakers, and the public
Does not set standards but focuses on expert analysis and scientific studies to reduce medication errorsSlide58
Medication Error
Reporting Systems
(continued)
Institute for Safe Medication Practices (ISMP)
Medication Errors Reporting Program (ISMP MERP)
ISMP provides legal protection and confidentiality for submitted patient safety data and error reports.
Allows the healthcare professional to report medication errors directly
ISMP shares all information and error-prevention strategies with the FDA.Slide59
Medication Error
Reporting Systems
(continued)
Other ISMP initiatives
Publishes checklist of strategies to prevent medication errors
Publishes a list of common look-alike and sound-alike drugs
Sponsors national forums on medication errors
Recommends additional labeling on potentially toxic drugs
Encourages revisions of potentially dangerous prescription writing practices
Disseminates information to healthcare professionals and consumers
Slide60
Chapter Summary
Pharmacy technicians play a crucial role in the prevention of medication errors.
Knowing the potential causes and categories of medication errors is the first step in preventing them from occurring.
Medication errors may result from physiological or social causes.
Medication errors can be further categorized as omission, wrong dose, extra dose, wrong dosage form, and wrong time of administration.
Once errors are identified by root-cause analysis, corrective measures should be put in place, and permanent elimination of the source of error should be the goal.Slide61
Chapter Summary (continued)
Each step of the medication-filling process has the potential to produce a medication error.
Specific practices, careful work habits, and a clean work environment promote patient safety and decrease illness and injury caused by medication errors.
Although pharmacy technicians cannot counsel patients concerning their medications, they can encourage them to ask questions of the pharmacist.
Helping patients become more informed also empowers them to be advocates for their own safety and health.Slide62
Chapter Summary (continued)
Automation and technological advances including e-prescribing and bar-code scanning can minimize medication errors.
Medication error prevention must be emphasized by al healthcare team members.
The pharmacy technician should adopt effective personal prevention strategies to minimize human errors.
Several medication error reporting systems exist. Pharmacy personnel should be familiar with these outlets and use them to confidentially report errors so that the errors do not occur again.
The Joint Commission has published an “unapproved abbreviations” list to minimize medication errors.Slide63