Medication errors; causes, types, and trends - PowerPoint Presentation

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Medication errors;causes, types, and trends

Youness R. Karodeh, B.Sc., Pharm.D., R.Ph

.

Assistant Dean, Associate Professor and

Director of Nontraditional Doctor of Pharmacy Program

Howard University, College of Pharmacy

Washington, D.C

.Slide2

Disclosure

I, Dr. Youness R. Karodeh hereby confirm that I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Slide3

Learning Objectives At the completion of this activity, the participant

should be able to:

Define Medication Error

Describe Impact of medication errors on the health care system.

List common causes of medication errors

Identify ways to prevent medication errorsSlide4
Slide5

Do You Know Who Emily Jerry & Eric Cropp

Are?

5Slide6

Pharmacist going to jail

Victim of pharmacy error?

https://www.youtube.com/watch?v=iru56ZO9tKc

6Slide7
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Estimated Deaths Due to Medical Error

Source: Philadelphia InquirerSlide9

Deaths due to Medical Error

“

44,000 to 98,000 unnecessary deaths each year”

More Americans are killed in US hospitals every 6 months than died in the entire Vietnam War

Death rate equivalent to three “jumbo” jet crashed every two days

Medication errors are a national concern.Slide10

How medical errors rank as cause of mortality

Accidents

123,706

Medical

Errors

~100,000

Alzheimer's

74,632

Diabetes

71,382

Heart

616,067

Cancer

562,875

Stroke

135,952

Lung

127,924 Slide11

pharmacy true incidence STORIES

A pregnant woman was given a RX

fo

..

Propylthiouracil “PTU” early in her pregnancy for her thyroid RX was filled & refilled with Purinethol/mercaptopurine, (used to treat leukemia).SAL, both Rx 50 mg dose, stored near one another…..baby was aborted.

A female Pt was prescribed

norinyl

but

RX..

was

filled with nardil (antidepressant). she delivered a baby girl. Patient was never counseledA patient was given tamoxifen..( for breast cancer)..”The hand writing was very difficult to read”. The RPh interpreted it as tambocor (anti-

arrthythmia

). This was filled and refilled 3 times before discovery and the cancer spread.

Dan and his friend went to see his ophthalmologist..

for glaucoma. They got their eye drops. 1 month later Dan finished his eye drop and asked the friend for a few drops till he can see his doctor tomorrow. Dan instilled 2 drops of the friend’s med to each eye. A few minutes later Dan started wheezing and suffered an acute asthma attack, and within 30 mins Dan died. Dan had asthma and the eye drop Dan borrowed was a B blocker, Contraindicated in asthma. Dan was never counseled by Pharmacist.A new pharmacist just out of school, was assigned.. to a busy store where they had a “15 mins Policy” to fill a Rx. The Rx was Methotrexate 10mg 1 weekly. Which is the usual dose. The new R.Ph filled it for Methotrexate 10mg 1 daily. The error was discovered during counseling. A patient has been using Lantus insulin from a multiuse insulin vial using hypodermic syringes.. “75 units Q AM. This time the doctor prescribed Lantus SoloSTAR pen, to inject 75 units Q AM. The patient was not counseled by the prescriber or the pharmacist. The dose is set in the pen’s dosing window by turning a dosage knob. The dose is then released by pressing an injection button, which moves a plunger within the pen’s insulin reservoir. The Pt expected the plunger to move like the typical hypodermic syringe. The pt did not know nor noticed the subtle movement and repeated the injection 3 times delivering 75 units each time. She got 225units. She went into a coma and was rushed to the ER. She survived.In CA, a premature baby was given a Rx..for Reglan.. to take 0.7ml. The Rx was filled correctly. The tech handed the bag to the mother and told her to give 7ml. The woman went home and gave the baby 7ml. The baby was rushed to the hospital, and survived. The parents sued. The R.Ph was found guilty of negligence.Slide12
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Medication error 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. 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.”

National Coordinating Council for Medication Error Reporting & Prevention (NCC MERP)Slide14

 Background

1999 Institute of Medicine (IOM) report entitled “To Err Is Human:” Building a Safer Health System drew national attention to the occurrence, clinical consequences, and cost of medical errors in the United States.

Estimated that in U.S. alone between 44000 and 98000 deaths result each year from

medical

errors, of which

medication

errors account for over 7000 deaths annually 

2007 Institute of Medicine (IOM), Over 1,000,000 injuries or deaths from adverse drug events in hospitals

(Institute of Medicine.

Preventing Medication Errors.

Washington, DC: National Academies Press;2007). 2006 IOM report “Preventing Medication Errors,” estimated that at least 1.5 million patients are harmed each year by medication errors, costing the U.S. health care system billions of dollars annuallyMedication errors remain a national concern for patient safety and for liability concerns.Slide15

Glossary……..medication errorsSlide16

Why Do So Many Mistakes Occur? Human Error;Extensively studied in other industries

Cognitive psychologists divide errors into:

Errors occurring in “automatic mode”

Slips

Occur during fatigue, interruptions, anxiety

Errors occurring in “problem solving mode”Mistakes

Occur due to incomplete knowledge and the tendency to apply rules to simplify problem solvingSlide17

UNSAFE ACT

(“An error or a violation committed in the presence of a potential hazard”)

An unsafe act may be categorized as:

A- Errors

: Can further categorized as:

Slips

,

Lapses,

and

Mistakes

B-Violations

Errors can be divided into two (2) types of Failure:

1

- An action that

does

go as intended, but it’s wrong one

2

- An action that

does

not go as intended, so called error of execution

Mistake

: it involves failure in planning.

Examples:

R.Ph on her way to work commits a

mistake by not adequately assessing the driving condition on a wet & cold road, skidding out of control at red light on “black ice”.Lapse: if action is not observable.Example: it’s some form of memory failure, such as failing to administer a medication- no one can see your memory fail, so the error is not observable.

Example:As traffic begins to flow, R.Ph experiences a lapse (preoccupied with black ice), she fails to recognize the light has turned green. She’s startled when she hears cars honking behind her.Slip: if action is observable.Example: accidentally pushing the wrong button on a piece of equipment- you and others can see that you pushed the wrong button.Example:Pulling into the hospital’s parking lot, she commits a slip when, distracted by her pager, she nearly drives through a gated entry point.Slide18

Why is medicine so susceptible?Lack of awareness to the problem“Culture of Silence”

Blame and shame mentality

System constraints

Staffing problems

Fatigue

Knowledge requirements

Communication and continuity of careSlide19

THE MEDICATION USE PROCESS

Medication use is a complex, multistep process that involves several individuals at various

locations. The medication use process comprises the subprocesses of:

Prescribing

Transcribing

DispensingAdministering

Monitoring

Patient education

Within the medication use process are interrelated key elements that form the structure within

which medications are used. The institute for Safe Medication Practices (ISMP) has identified ten

(10) key system elements that have The greatest influence on medication use:1. Patient information.2. Drug information.3. Communication related to medications.

4. Drug labeling, packaging, and nomenclature.

5. Drug standardization, storage, and distribution.

6. Medication delivery device acquisition, use and monitoring.

7. Environmental factors.8. Staff competency and education.9. Patient education. 10. Quality processes and risk management.Source: Medication Errors, 2nd editionSlide20

Prescribing Errors

Involve the prescriber inappropriately selecting a drug (based on indication, contraindication, known allergies, existing drug therapy, and other factors), dose, dosage form, quantity, route of administration, concentration, rate of administration, or providing inappropriate or inadequate instructions for use.

Errors and deficiencies in the prescribing step of the medication use process are common and account for a large proportion of the preventable injuries due to medication errors.

 Slide21

Factors Related to Errors in Medication Prescribing

Objective:

To quantify the

type

and

frequency

of identifiable factors associated with medication prescribing errors.

Design and Setting:

Systematic evaluation of

every third

prescribing error detected and averted by pharmacists in a 631-bed tertiary care teaching hospital between July 1,1994, and June 30, 1995. Each error was concurrently evaluated for the potential to result in adverse patient consequences. Each error was retrospectively evaluated by a physician and 2 pharmacists and a factor likely related to the error was identified.Participants: All physicians prescribing medications during the study period and all staff pharmacists involved in the routine review of medication orders.Main Outcome Measures: Frequency of association of factors likely related to medication errors in general and specific to medication classes and prescribing services (needed for medical, pediatric, obstetric-gynecologic, surgical, or emergency department patients); and potential consequences of errors for negative patient outcomes.

Results:

A total of

2103 errors

thought to have potential clinical importance were detected during the 1-year study period. The overall rate of errors was 3.99 errors per 1000 medication orders, and the error rate varied among medication classes and prescribing services. A total of 696 errors met study criteria (ie, errors with the potential for adverse patient effects) and were evaluated for a likely related factor. The most common specific factors associated with errors were decline in renal or hepatic function requiring alteration of drug therapy (97 errors, 13.9%), patient history of allergy to the same medication class (84 errors, 12.1%), using the wrong drug name, dosage form, or abbreviation (total of 79 errors, 11.4%, for both brand name and generic name orders), incorrect dosage calculations (77 errors, 11.1%), and atypical or unusual and critical dosage frequency considerations (75 errors, 10.8%). The most common groups of factors associated with errors were those related to knowledge and the application of knowledge regarding drug therapy (209 errors, 30%); knowledge and use of knowledge regarding patient factors that affect drug therapy (203 errors, 29.2%); use of calculations, decimal points, or unit and rate expression factors (122 errors, 17.5%); and nomenclature factors (incorrect drug name, dosage form, or abbreviation) (93 errors, 13.4%).Conclusions: Several easily identified factors are associated with a large proportion of medication prescribing errors. By improving the focus of organizational, technological, and risk management educational and training efforts using the factors commonly associated with prescribing errors, risk to patients from adverse drug events should be reduced.Timothy S. Lesar, PharmD; Laurie Briceland, PharmD; Daniel S. Stein, MD. JAMA. 1997;277(4):312-317. doi:10.1001/jama.1997.03540280050033Slide22

transcriping errors

A substantial number of the medication errors identified at community pharmacies that reach patients have possible clinical significance. Root-cause analysis shows potential for identifying the underlying causes of the incidents and for providing a basis for action to improve patient safety.

Most of these errors were made in the transcription stage, and the most serious were errors in

strength

and

dosage

. The analysis shows four root causes:

handwritten

prescriptions

; “traps” such as similarities in packaging or names, or strength and dosage stated in misleading ways; lack of effective control of prescription label and medicine; and lack of concentration caused by interruptions.Slide23

Dispensing Errors

Can occur during any stage of the dispensing process

-From receipt of a prescription in the pharmacy through the supply of the product to the patient.

Involve the failure to dispense a medication; dispensing of an incorrect drug, dose, or dosage form; failure to dispense the correct amount of medication; inappropriate, incorrect, or inadequate labeling of medication; incorrect or inappropriate preparation, packaging or storage of medication prior to dispensing; or dispensing of expired, improperly stored, or physically or chemically compromised medications.

The most common types of dispersing errors involve the patient receiving the wrong drug or the wrong strength.

Dispensing errors are occurring in numbers well above reports to regulatory authorities or professional indemnity insurance companies, and seem to be accepted as part of practice. High prescription volumes,

pharmacist fatigue

and

overwork

appear to be important factors. Pharmacists have a role in managing and improving each step of the medication process.

G. M. Peterson PhD FSHP M. S. H. Wu J. K. Bergin BPharm MBA First published: 24 April 2006 https://doi.org/10.1046/j.1365-2710.1999.00199.xSlide24

Dispensing Errors….Continued

In 2007, community pharmacies dispensed 3.8 billion prescriptions. Pharmacists have direct responsibility for accurately filling and dispensing prescription orders- dispensing errors are a critical concern for the practice of pharmacy.

Published studies regarding medication errors in community pharmacies are limited:

- Overall dispensing error rates range form from

0.26% to 24%

-

0.1% to 4%

of prescriptions dispensed had the potential to contain clinically significant errors that could cause patient harm or discomfort.

Using a conservative estimate of 1% overall dispensing error rate, this would translate to over 30 million dispensing errors in the US each year.Slide25

DRUG Administration ErrorsInvolve a discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber.

-Examples include timing errors, omissions, incorrect drug administration techniques, wrong route of drug administration, and administration of an improper dose.

One of the most common types of medication errors and are a major source of harm to hospitalized patients.Slide26

Medication Errors Observed in 36 Health Care Facilities

Objective

To identify the prevalence of medication errors (doses

administered

differently than ordered).

Design

A prospective cohort study.

Setting

Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado.

Participants

A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication–volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered.Methods Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians.Main Outcome Measure

Medication errors reaching patients.

Results

In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P = .82) or by size (P = .39). Error rates were higher in Colorado than in Georgia (P = .04)

Conclusions Medication errors were common (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 in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Ginette A. Pepper, PhD; et al David W. Bates, MD, MSc; Robert L. Mikeal, PhDAuthor Affiliations Article InformationArch Intern Med. 2002;162(16):1897-1903. doi:10.1001/archinte.162.16.1897Slide27

Monitoring ErrorsInclude failure to review a prescribed regimen for appropriate treatment or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to the prescribed therapy.

Studies suggest that up to 3 % of hospitalized patients could experience preventable injuries due to monitoring errors.Slide28

Categorizing medication errors

B- an error

occurred

but

did not

reach the patient

C- error

reached

the patient but

did not

cause harm

D- patient monitoring required to determine lack of harm

E-

error caused temporary harm and some intervention F- temporary harm with initial or prolonged hospitalization G- error resulted in permanent patient harm H- error required intervention to sustain the patient’s life I- error contributed to the patient’s

death

A-

circumstances exist for potential errors to occurSlide29

Patient Harm ClassificationSlide30
Slide31
Slide32
Slide33
Slide34

Patient Adherence/ Misuse Concerns

Adherence concerns can occur once the patient leaves the prescribers office, pharmacy or hospital.

Patient adherence with a medication regimen is generally defined as;

“

The extent to which patients take medications as prescribed by their health care providers”

Poor adherence to medication regimens is common, and contributes to substantial increases in disease, death, and health care costs. 

Nonadherence, or medication misuse, may be exhibited by patients in many ways, such as not having a prescription initially filled or refilled, missing doses, taking the wrong dose, taking the dose at the wrong time, and/or stopping a medication without the advice of a healthcare professional. 

Lack of patient education can also lead to misuse.Slide35
Slide36
Slide37

Safe Medication UseFive Rights” of safe medication use: Right patient

Right drug

Right time

Right dose

Right routeSlide38

A system approachSystem: A system is a perceived whole whose key elements hang together, continually affecting each other, as it moves toward a common purpose.

Where medication errors are concerned, finding out who was involved is (blame & train) less important than learning what went wrong, how and why

There is a broad categories, or domains, where the underlying problems that result in medication errors may be found. Slide39

Medication Errors: Why82% of Pharmacists believe: risk of dispensing error is increasing. Why?

High prescription volume

Distractions

Shortage of Support Personnel

Look-Alike / Sound Alike drug names

Inadequate opportunity to counsel

Illegible Handwriting

FatigueSlide40

Massachusetts Board of pharmacyTHE MOST COMMON CAUSES OF ERRORS IN YOUR OPINION (Audience survey)

Massachusetts Board of Pharmacy Study showed that the Most Common Causes of Error Cited by Pharmacists:

Distractions & Interruptions!

-

To many phone calls (62%)

-Overload/unusually busy day (59%)

-Too many customers (53%)

-Lack of concentration (41%)

-No one available to double-check (41%)

-Staff shortage (32%)

-Similar drug names (29%)

-No time to counsel (29%)

-Illegible prescription (26%)

-Misinterpreted prescription (24%)

Distractions & Interruptions!-To many phone calls-Overload/unusually busy day -Too many customers -Lack of concentration -No one available to double-check -Staff shortage -Similar drug names -No time to counsel -Illegible prescription-OthersSlide41

Proximal causes of medication errors….multifactorial in natureLack of knowledge of the drug,

Lack of information about the patient,

Violation of rules,

Slips and memory lapses,

Transcription errors,

Faulty identity checking,

Faulty dose checking

Malfunctioning devices,

Inadequate patient monitoring,

Drug stoking and delivery problems,

Preparation errors,Lack of standardization.Source: Medication Errors, 2nd editionSlide42

System elements implicated in errorsThe system-based causes of errors can best be uncovered through

interdisciplinary efforts, since they stem from weaknesses in systems

throughout an organization.

Organizationwide system weaknesses are often identified in:

How information is collected and communicated,

How colleagues interact

How patient and staff are educated

How the organizational culture/physical environment are managed,

How staff is provided to carry out patient care functions,

How staff learns about system errors and their causes,

How patient are safeguarded from harm.Source: Medication Errors, 2nd editionSlide43

Take home messageWhen an error occurs, it is tempting to blame individuals (punitive approach).

Analyzing errors in an interdisciplinary, systems-based context avoids punitive

approach.

A system-based approach

does not remove individual accountability

for

medication safety; rather it expands accountability to all who could potentially

influence the medication-use process.Slide44

Medication Errors: Root CausesFailed Communication (next slide…..lost in translation)Poor Communication within Health Care Team

Verbal Orders

Poor Handwriting

Incorrect Scheduling

Improper Drug Selection

Dose MiscalculationsPoor Drug Distribution PracticesDrug & Drug Device Related Problems

Incorrect Drug Administration

availability of Floor Stock, hence no 2

nd

check

Lack of Patient EducationPolypharmacySlide45

lost in translation Patient: It’s been one month since my last visit, and I still feel miserable.

Doctor

: Did you follow the instructions on the medicine I gave you?

Patient

: Sure did. The bottle said “ keep tightly closed.”Slide46

Medication Errors: Addressing Root CausesAddressing failed communication : Medical staff priority!

Handwriting

Look Alike / Sound Alike Pairs

Zeros & Decimal Points

Abbreviations

Ambiguous or incomplete ordersMetric vs. apothecary systemSlide47

Error-Prone Abbreviations and Dose ExpressionsSlide48

Root Cause Analysis of Medication ErrorsRoot cause analysis (RCA) is used to identify underlying reason(s) for the occurrence of an adverse event or close call (near miss) to find out:

What happened?

Why did it happen?

What will prevent reoccurrence?Slide49

The Role of Drug Names in Medication ErrorsConfusion related to product names is one the most common causes of medication errors reported.

The ISMP

Medication Safety Alert

! Newsletter has published many examples of errors related to handwriting, such as the following:

Daptomycin (Cubicin) and Dactinomycin (Cosmegen)

Mucomyst (acetylcysteine) and Mucinex (guaifenesin)Purinethol (mercaptopurine) and PropylthiouracilSlide50

The Role of Drug Names in Medication ErrorsNames Changes: some trademarks have been changed in response to serious medication errors.

Examples;

Lanoxin (0.125 mg po qd) and Levoxine (0.125 mg po qd)

Losec (20 mg po qd) and Lasix (20 mg po qd)

Use of Tall-Man Letters: Tall-man letters have been used successfully to alert health professionals.

Examples;

hydrOXYzine and hydrALAZINE

glipiZIDE and glyBURIDE

An extensive list of look-alike and sound-alike medication names that have been involved in errors can be found at;

www.ismp.org/tools/confuseddrugnames.pdfSlide51

Take home messagePatient safety clearly requires improved methods for naming pharmaceutical

products.

Hence, there must be a renewed collaborative efforts on all related agencies

and pharmaceutical industries on a guidance document for product naming.

Such guidance should propose a common nomenclature with standardized

abbreviations, acronyms, and terms.

Although there is no single or simple answer to reducing medication errors, a

new coordinated effort by all stakeholders to research problems associated

with drug naming should lead to a plan to action that produces timely and

measurable results. Slide52

The role of drug packaging and labeling in medication errorsBoth consumers and health care practitioners use product packaging and labeling to select the correct medication and dose.

Ambiguous and confusing packaging and labeling as well as look-alike or sound-alike drug names significantly contribute to medication errors. In fact, a frequent (29%) cause of pharmacy drug dispensing errors is failure to accurately identify drugs, usually due to look-alike or sound-alike drug names.

Triple read ruleSlide53

Look-alike packagingSlide54

Look-alike packagingSlide55

Look-alike packagingSlide56

Sound-alike medication names Confusing drug names is a common system failure. Unfortunately, many

drug names can look or sound like other drug names, which may lead to

potentially harmful medication errors. Increasingly, pharmaceutical

manufacturers and regulatory authorities are taking measures to

determine if there are unacceptable similarities between proposed names

And products on the market. But factors such as poor handwriting or

poorly Communicated Oral prescriptions can exacerbate the problem.

For a complete listing of sound-alike and look-alike drug names visit the

Following web site:

http://www.ismp.org/Tools/confuseddrugnames.pdf Slide57

The role of drug packaging and labeling in medication errors

Use of color

Color coding (see next slide)

Color matching (see next slide)

Two-sides labeling

ContrastExpression of concentration and strength

Labeling of blister strips

Company name, logo, and corporate dress

Symbols

Standardization of terminology

Label reminders and warningsTypefaceExpressing product expiration datesUse of unsafe abbreviations and dose designationBar codesContainer designProtective overwrapsExternal carton labelsPromotional items and advertisements

brand name extensions for nonprescription drugs

Drug shortagesSlide58

A Unique Color for Each Total Strength of HEPARIN Sodium Injection, USP

Helps caregivers distinguish among HEPARIN products; minimizes the risk of medication confusion

Unique color designation for each total strength.

The cap, label and carton match for each total strength are color coordinated.

Courtesy of SAGENT PharmaceuticalsSlide59

Preventing Prescribing ErrorsAlthough the root causes of medication errors reside in systems, each individual health care professional, beginning with the prescriber, must take every possible precaution to prevent errors.

It is the prescriber responsibility to communicate complete information about the prescribed medication in a manner that is clear to the other health providers and patients who must carry out the order or take the medication.Slide60

Preventing Dispensing ErrorsPharmacies are responsible for dispensing medications accurately.Research shows 98.3% accuracy in dispensing. However, if 1.7% of medications are dispensed inaccurately, that translates to 4 errors per day per 250 prescriptions, or 51.5 million errors in the 3 billion medications dispensed each year in theSlide61

Steps for ensuring accurate dispensing1-

lock up or sequence drugs that could cause disastrous errors.

2- Develop and implement meticulous procedures for drug storage.

3- Reduce distractions, design a safe dispensing environment, and maintain optimum work flow.

4- Use reminders such as labels and computer notes to prevent mix-ups.

5- Keep the original prescription order, label, and medication container together throughout the dispensing process.

6- Compare the contents of the medication container with the information on the prescription.

7- Enter the drug’s identification code (NDC)

8- Perform a final check on the prescription, the prescription label, and the manufacturer’s container.

9- Perform a final check on the contents of prescription containers

10- Provide patient counseling.Slide62

Do Patients a have Role in Preventing Medication ErrorsSlide63
Slide64

The Patient’s Role in Preventing Medication ErrorsPatients can do a great deal to decrease their chances of experiencing a medication error.

Most pharmacist, physician, and consumer advocates believe that to ensure safe medication use, all patients must have the answers to the following questions:

1- Brand/generic names

2- Purpose

3- Strength and dosage

4- Adverse effects, and what do if occur?

5- What to avoid (med, food, etc.)

6- Allergies

7- Therapy duration and outcome expected

8- Best time to take

9- Storages10- Miss dose11- Current medication

12-Written informationSlide65

Managing errorsJUST CULTURE

Concept

You are a fallible human being, susceptible to human error and behavior drift

Human error

At-risk behavior

Reckless behaviorSlide66

“Just Culture”

Human error

Inadvertently doing other than what should

have been done; a slip, lapse, or mistake.

Manage through:

• Choices

• Procedures

• Training

• Design

• Environment

ConsoleSlide67

“Just Culture”

At-risk behavior

A behavioral choice that increases risk where risk is not recognized, or is

mistakenly believed to be justified.

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

CoachSlide68

“Just Culture”

Reckless behavior

A behavioral choice to consciously disregard a substantial & unjustifiable risk.

Manage through:

• Remedial action

• Punitive action

PunishSlide69

Treating the employee (second victim)Slide70

Dealing with the SECOND VICTIM in a “Just Culture” environment

Leslie, age 45, an RN with 23 years of pediatric experience.

She made a mathematical error that led to an overdose of calcium chloride and the subsequent death of a critically ill infant.

She was fired; her licensing board made her pay a fine and placed her on 4 years probation.

Despite receiving a perfect score in an advanced cardiac life support certification exam, she was refused work and could not find a job. Slide71

Dealing with the SECOND VICTIM in a “Just Culture” environment

With no job offers, she experienced increasing isolation, despair, regret, hopelessness, low self-esteem, and shame and guilt regarding her role in the fatal error

Leslie took her own life 9 months after the death of her patientSlide72

Dealing with the SECOND VICTIM in a “Just Culture” environment

TRUST

Treatment that is just

Respect

Understanding and compassion

Supportive care

Transparency and opportunity to contribute

Source: Denham C. TRUST: the 5 rights of the second victim. J Patient

Saf. 2007;3(2):107-119. Slide73

Medication Errors: Med Safety ImprovementsNational Efforts to Improve Med SafetyCoordinated efforts of FDA, ISMP, USP, & NCC MERP

FDA

Division of Medication Errors & Technical Support

Eliminate confusion of Look Alike Sound Alike names

Require Bar Codes on packaging

NCC MERP (National Coordinating Council for Medication Error Reporting & Prevention)

Recommendations to reduce errors

All written prescriptions/orders must be legible

Prescribers should avoid the use of abbreviations

All prescriptions should be written using the metric system

Prescribers should provide age/weight of patient on prescriptionPrescriptions should always include drug name, dosage formLeading zero before decimal, no trailing zeroSlide74

Medication Errors: Med Safety Improvements

ISMP (Institute for Safe Medication Practices) Published

tools and resources for medication safety:

ISMP list of Confused Drug Names

http://www.ismp.org/Tools/confuseddrugnames.pdf

ISMP High-Alert Medication List

http://www.ismp.org/Tools/highalertmedications.pdf

ISMP “Do Not Crush” List

http://www.ismp.org/Tools/DoNotCrush.pdfSlide75

Medication Errors: Med Safety ImprovementsCharacteristics of a Pharmacy Optimized for Medication Safety

Bar Code Medication Administration (BCMA)

Smart Infusion Pumps

High Alert / High Risk Medication Policy

Safe Drug Nomenclature, LASA practices

Use of Preprinted Order SetsComputerized Prescriber Order Entry (CPOE)

Computer Decision Support

Availability of Patient Information

Pharmacy Maintained Medication Administration Record

Education : Patients, Care GiversSlide76

Medication Error: StrategiesCharacteristics of Pharmacy Services Optimized for Med SafetyPharmacy performed med history/med record

Pharmacist role on patient care team

Discharge counseling/med record

Patient care rounding

Measure pharmacist impact

Integration of documentationFocus on core quality performance measures

Standard med administration times

Patient surveysSlide77

Medication Error: Strategies to Reduce ErrorsIncrease awareness of at-risk populations

Pediatric

Geriatric

Increase awareness of High Risk/High Alert Medications

LASA pairs

Tall Man lettering (laMICtal /LAMisil)

Physical separation

Double/Triple checks

PreMix

Pharmacist Monitoring/DosingSlide78

Medication Error: Strategies to Reduce ErrorsAvoid abbreviations/nomenclatureBeware of OTC family extensions/labeling

Duplicate therapies/interactions/coordination of care

Don’t shortcut around technological safeguards

Report Errors to improve process

Failure Modes & Effects Analysis

Root Cause AnalysisEducate Caregivers

Educate the PatientSlide79

Medication Error: Strategies to Reduce ErrorsEvaluate ErrorFailure Modes and Effects Analysis

Prospective systematic approach to safety

Document process

Determine how it can fail

Why the failure occurs

Redesign process to decrease failuresTest new processImplement strategy to maintain effectiveness of new process

AuditSlide80

Strategies to Reduce Med. Errors

Specific strategies for pharmacy practitioners that can help reduce and

prevent medication errors and improve patient safety include:

-implement professional standards and training

-incorporate automation and computer cross checks

-educate pharmacy staff on look-alike and sound-alike drug names

-incorporate electronically-generated prescriptions

-redesign pharmacy dispensing areas

-incorporate computerized systems that provide alerts on potential errors

-make verbal counseling a part of each prescription dispensedSlide81

Strategies to Reduce Med. Errors

Remain educated on medication errors and strategies that can be utilized to prevent them.

Use available resources and guidance to improve patient safety such as those available from the FDA and the institute for Safe medication Practices (ISMP)

The FDA has a Medication errors website, available at:

http://ww.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm

-The ISMP website

http://www.ismp.org

Subscribe to Institute for Safe Medication Practices (ISMP) & Pharmacy Times Publication Safety Alert ! Community/Ambulatory Care Edition by calling 215-947-7797 or send an e-mail to

community@ismp.org

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Strategies to Reduce Med. Errors

Medication error Reporting

-The primary reason to report medication errors is for the health care system to learn how to improve the medication use process.

-Medication error reporting is critical in the identification of system deficiencies that can be corrected to prevent future errors.

-At the national level, anyone can voluntarily and confidentially report medication errors, or near misses to either:

MERP available at

www.ismp.org

or

FDA MedWatch program at

www.fda.gov

Phone: 1-800-FDA-1088Fax: 1-800-FDA-0178Slide83

Strategies to Reduce Med. Errors

Medication Error Reporting:

-Reported medication errors are entered into a network of databases that analyze the information and then allows patient safety organizations to share recommendations with drug manufacturers and healthcare providers regarding guidelines, protocols, or best practice steps to take to minimize future occurrences.

-In addition to reporting medication errors voluntarily, pharmacists should also verify with their employers and state administrative agencies of there are additional medication error reporting requirements.Slide84

Strategies to Reduce Med. Errors

Quality Assurance Programs

- Medication error prevention should also include a comprehensive quality

assurance program

-The importance of undertaking such programs has been recognized at

the national level and is mandated by various federal & state administrative agencies

-Continuous Quality improvement (CQI) programs are a comprehensive approach to improve patient safety that allows pharmacies to create a proactive, non-punitive environment that encourages the identification of error, evaluating causes, and designing systems to prevent future errors.

-CQI is a system based solution that recognizes that the system that caused or contributed to errors can be modified and improved to be more efficient and effective

 Slide85

Strategies to Reduce Med. ErrorsPatient Counseling

-Pharmacist-patient interactions, such as counseling, have a significant role in identifying medication errors before they occur.

-Counseling is an opportunity to educate patients about their medications and to verify the accuracy of dispensing and the patients understanding of proper medication useSlide86

Is this for real?Doctor: Take this RX and have it filled, and take one daily and don’t forget to exercise, running 3 miles a day is not a bad idea.

Two months later…..

Doctor

: how are you doing?

Patient

: My BP is under control, but my sex life is miserable!!!!!

Doctor

: How come

Patient

: I am 180 miles a way from home.Slide87

Accurate Rx Filling & work flowSlide88

Potential Legal Consequences Associated with rx Med. Errors

Civil

-

Malpractice action where an injured patients sues the pharmacy/pharmacist for harm caused by a medication error. If successful, the patient will receive a monetary award

.

Administrative

-

Action taken by the state board of pharmacy against professional license. Discipline could result in public reprimand, monetary fine and/or license probation, suspension, or revocation

Criminal

-

Involves criminal charges, such as manslaughter or reckless homicide, against the pharmacist as a result of a medication error that caused patient death. If convicted, penalties could involve probation or jail sentence. Slide89

SUMMARY Pharmacists have a vital role in managing and improving each step of the medication use process. It is imperative for pharmacists to be educated regarding medication errors, as well as strategies that can be implemented to prevent them.

It is also important for pharmacy providers to understand the potential legal consequences that may arise from medication errors. In addition to civil malpractice actions, pharmacists may also have to contend with administrative and criminal actions. By preventing medication errors, patient safety is improved and the potential for subsequent legal consequences is decreased.Slide90
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References/ Acknowledgements

Medication Errors (American Pharmacists Association), Edithed by Michael R. Cohen

Second Edition.

Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies

. J Am Pharm Assoc

. 2003;

43:19 1-200

Medication Errors Observed in 36 Health Care Facilities.

Arch Intern Med. 2002;162(16):1897-1903. doi:10.1001/archinte.162.16.1897. visited 8/21/2018

 Kistner UA, Keith MR, et al. Accuracy of dispensing in a high volume hospital based outpatient pharmacy. Am J Hosp Pharm. 1994; 51:2793-2797. Burns, K. Reducing Prescription Medication errors: What You Need to Know and What Your Patients Should Be Told. Powerpak Continuing education Monograph, published Oct. 1, 2008.

David Brushwood,

Medication Error Reduction Perspectives from Two States with Legal Case Analysis

, March, 2005. Brienze v. Casserly. 2003. WL 23018810 (Mass.Super.)  Ohio State Board of Pharmacy. Order of the state board of pharmacy in the matter of Eric Jean Cropp, R.Ph. Doc No D-061109 -012. 2007 May Medication Errors (American Pharmacists Association), Edithed by Michael R. CohenJoy P. Alonzo, Pharm.D. Pharmacy Clinical Specialist.ISMP list of Confused Drug Nameshttp://www.ismp.org/Tools/confuseddrugnames.pdfISMP High-Alert Medication Listhttp://www.ismp.org/Tools/highalertmedications.pdfISMP “Do Not Crush” Listhttp://www.ismp.org/Tools/DoNotCrush.pdfwww.fda.gov

www.ismp.org/tools/confuseddrugnames.pdf

ETC, ETCSlide95
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CE access code and instructions to process ce

Participants have until

November 6, 2018

to earn 1.0 contact hour of Continuing Pharmacy Education (CPE) credit for this activity by full session attendance/participation AND successful completion of the online activity evaluation and post-assessment test. Access to the evaluation and test is through use of the CE access code as displayed on this slide.

After November 6th, 2018

NO CE credit will be available for this program. Credits will be transferred electronically to the CPE Monitor System.

CE Access Code

MedE

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