LESSON 5: Medication Safety Flashcards
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”
Medication Errors
According to National Coordinating Council for Medication Error Reporting and Prevention, such events (Medication Error) may be related to:
professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use
It has been reported that __________ are among the commonly encountered medical problems in clinical practice, one of these is medication error.
Adverse drug effects
Medication errors can lead to _________ if not recognized or managed accordingly.
Fatalities
Generally occur as unsafe acts which are committed in the background of a potential hazard. This is a result of __________
System failure
Proposed by James Reason in 2000. He said that ideal system is analogous to a stack of slices of swiss
cheese.
Swiss Cheese Model of Accident Causation
In the swiss cheese model, these are considered as opportunities for a process to fail.
Holes
In the swiss cheese model, these are defensive layers in the process. It is a defense against potential error impacting the outcome
Each slices
In the swiss cheese model, this may allow a problem to pass through a whole in one layer.
Error
In the swiss cheese model, in the succeeding layers, holes are in _________ such that the problem is caught and addressed.
different places
In the swiss cheese model, if a hole in one layer coincides with the holes in the next layers, the problem is allowed to _______ and can eventually lead to an adverse outcome.
pass through
A general type of error that involves administering a drug without having established whether a potential adverse event or reaction will occur.
Ex. When one gives penicillin without checking whether the patient has a history of allergy or not.
Knowledge-based errors
A general type of error that involves using a bad rule or misapplying a good rule.
Ex. Injecting diclofenac in lateral thigh rather than in buttocks.
Rule-based errors
A general type of error that involves slips in which certain practices were done incorrectly.
Ex. Dispensing a drug Leponex (Generic: Clozapine), an
atypical antipsychotic medication, instead of Ceporex (Generic: Cefalexin), a cephalosporin antibiotic, or picking up a bottle of Gabapentin, an anticonvulsant for Gemfibrozil, a lipid-regulating drug.
Action-based errors
Medication errors can occur in every of the ____________.
Medication process
A general type of error that involves lapses in which steps in the medication process are missed.
Ex. Failure to administer antibiotics prior to surgical operation.
Memory-based errors
A specific type of error that includes Incorrect drug selection (based on indications, contraindications, known allergies, existing drug therapy, and other factors), dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician (or other legitimate prescriber); illegible prescriptions or medication orders that lead to errors that reach the patient.
Ex. [Case Study 1] Patient received a total of 16,000 mg/m2 instead of a 4000 mg/m2, an incorrect drug dose.
Prescribing errors
A specific type of error that includes an error in drug dispensing (type and dose) as a result of outdated or incorrect drug reference information, poor work environment, suboptimal packaging, labeling of products, interpretation of prescriptions, failure to double-check orders.
Ex. [Case Study 2] The prescription drug name Avandia (Rosiglitazone maleate) was incorrectly interpreted as Coumadin (Warfarin) by the pharmacist.
Dispensing errors
A specific type of error that involves a medication administration error which includes administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient, i.e., one or more dosage units in addition to those that were ordered.
Improper dose error
A specific type of error that involves a medication administration error which includes failure to administer an ordered dose to a patient before the next scheduled dose, if any.
Omission error
A specific type of error that involves a medication administration error which includes administration of medication outside a predefined time interval from its scheduled administration time (this interval should be established by each individual health care facility)
Wrong time error
A specific type of error that involves a medication administration error which includes inappropriate procedure or improper technique in the administration of a drug.
Ex. Giving Vitamin K1 as a bolus instead of as a push
Wrong administration-technique error
A specific type of error that involves a medication administration error which includes administration to the patient of medication not authorized by a legitimate prescriber for the patient.
Ex. Administration of an over-the-counter medication which was not previously approved by the attending physician or a drug which has no proven therapeutic indication.
Unauthorized drug error
A specific type of error that involves a medication administration error which includes administration to the patient of a drug product in a different dosage form than ordered by the prescriber.
EX. Giving the drug through parenteral form rather than in oral preparation.
Wrong dosage-form error
A specific type of error that involves a medication administration error which includes incorrectly formulated drug product or manipulated before administration and incorrect dilution or reconstitution, mixing drugs that are physically or chemically incompatible.
Wrong drug-preparation error
A specific type of error that involves a medication administration error which includes administration of a drug that has expired or for which the physical or chemical dosage-form integrity has been compromised.
Ex. Administration of a drug 3 months after expiration date.
Deteriorated drug error
It’s very important that patients are provided with appropriate information and advice because if they are not given so, ___________ may happen.
Ex.
Case 4: 45-year old female on methotrexate stopped taking the medication because of vomiting and diarrhea
Case 5: 54-year old male, maintained on warfarin, developed bleeding. Protimedetermination showed an INR of 7 which is prolonged.
Patient adherence errors
A specific type of error that involves a patient adherence error which includes inappropriate patient behavior regarding adherence to a prescribed medication regimen.
Compliance error
A specific type of error that involves a patient adherence error which includes failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy.
Monitoring error
Most ME occur but do not cause harm. These are labeled as __________.
Potential errors or Potential ADEs.
Some cause harm and they are either potential ADEs or ___________ depending on whether an injury has occurred.
preventable ADES
An end effect medication error that includes no harm happened because intervention may have been done to prevent an error to happen. Also known as near misses.
Potential ADE–ME occurred but no harm
An end effect medication error that take for instance BL from Case 1, a breast cancer patient who developed a drug overdose as a result of prescribing error. The end result is death which is a serious adverse event.
Preventable ADE–ME occurred and adverse reaction or harm was observed
An end effect medication error that includes an injury of which the severity or duration could have been substantially reduced if different actions had been taken.
Ex. Patient who was prescribed furosemide, which is a diuretic, for congestive heart failure and advised a follow-up visit with a cardiologist in 4 weeks, but no instructions for earlier follow-up or laboratory tests to be done. 10 days later, the patient presents to the emergency department with acute kidney injury and critically low potassium.
These adverse effects of diuresis are not preventable because these are adverse reactions of the drugs, but the severity could have been reduced by planning to have the patient come in for a laboratory testing within a week of discharge and while the patient is on furosemide for that first week.
Ameliorable ADE-ME
A factor that cause medication errors that involves the following:
● Inaccurate dosage calculation
● Inadequately trained personnel
● Excessive workload
● Lapses in individual performance
● Inadequate number of personnel
● Poor handwriting of prescribers
Provider
A factor that cause medication errors that involves the following:
Miscommunication of drug order
○ Improper transcription
○ Misuse of zeros and decimal points
○ Confusion of metric and other dosing units
○ Inappropriate abbreviations used in prescribing
○ Lack of appropriate labeling
Procedure
A factor that causes medication errors that involves an environment that is not conducive and safe to work in e.g., lighting, heat, noise, and interruptions can distract health professionals from their medical tasks, and stress.
Place (enviromental)
A factor that causes medication errors that involves the following:
● Unavailability or ambiguity of drug information
● Ambiguous strength designation on labels
● Unavailability of medication
● Confusion between drugs with look-alike or sound- alike names
Ex.
Look-alike or sound-alike names
- Zantac (Ranitidine) vs Xanax (Alprazolam)
Same brand names but with different ingredients
- Tylenol contains Paracetamol vs Tylenol PM which
consists of paracetamol and diphenhydramine
Product (drug itself)
A factor that causes medication errors that involves use of devices such as infusion pumps and equipment failure or malfunction.
Peripherals
A factor that causes medication errors that involves the following:
● Incomplete patient information
● Failure to elicit from patient the history of allergies and other adverse drug reactions
● Previous diagnoses
● Maintenance medications
● Laboratory results
Patient
A factor that causes medication errors that involves administration of non-formulary drugs and lack of standardized use of abbreviations.
Policies
A safety net that made use of:
● Patient-specific identifiers (name and date of birth; “name alert”; may include mother’s maiden name)
● Verification of allergies and reactions
● Highlighting critical diagnoses and conditions
● Updating current medications
● Standardizing height and weight measurements
● Taking note of patient’s occupation (guides doctor on drug selection and timing of intake)
Correct patient information
A safety net that made use of:
● Maintaining drug references (know the drug carefully:dose, route, rate, etc.)
● Establishing guidelines
● Identifying high-alert medications (warfarin, low molecular weight heparins, insulin,etc.)
● Knowing the drug manufacturer (quality and bioavailability)
● Checking for expiration dates
Correct drug information
Drugs that bear a heightened risk of causing significant patient harm when they are used in error (ISMP definition). Such harm can be DEVASTATING to a patient’s health!
High-alert medications
The following are:
○ Narrow therapeutic ranges
○ Low toxic-therapeutic ratios
○ Potential serious adverse effects (E.g. bleeding, hypoglycemia, arrhythmias, allergies)
○ Need frequent calculation of doses
○ Require specific rates of administration
○ Require specific diluents/IV fluids
Characteristics of High Alert Medication
A safety net that made use of:
● Separating problematic drugs
● Keeping the storage area well organized
● Avoiding over prescribing and overstocking (accidents, sharing, reselling)
● Not using if you cannot read the label (name, strength, expiration date)
Proper drug labeling and storage
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
Is there an indication for the drug?
Indication
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
Is the medication effective for the condition?
Effectiveness
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
Are there important comorbidities that could affect the response to the drug?
Diseases
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
Is the patient already taking another drug
with the same action?
Other similar drugs
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
Are there clinically important drug-drug interactions
with other drugs that the patient is taking?
Interactions
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
What is the correct dosage regimen (dose, frequency,
route, formulation)?
Dosage
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
What are the correct directions for giving the drug and are they practical?
Orders
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
What is the appropriate duration of therapy?
Period
One of the nine questions before writing a prescription that is included in the safety net: appropriate drug prescribing
Is the drug cost-effective?
Economics
This is an example of error prone abbreviation that is mistaken for zero, number 4, or cc. The alternative is to write it as it is.
U (unit)
This is an example of error prone abbreviation that is mistaken for IV or number 10. The alternative is to write it as it is.
IU (international unit)
This is an example of error prone abbreviation that is mistaken for QID. The alternative is to write “daily.”
QD (daily)
This is an example of error prone abbreviation that is mistaken for QID and QD. The alternative is to write “every other day.”
QOD (every other day)
This is an example of error prone abbreviation that includes a missing decimal point. The alternative is to write X mg.
Trailing zero (X.0 mg)
This is an example of error prone abbreviation that includes a missing decimal point. The alternative is to write 0.X mg.
Lack of leading zero (.X mg)
A safety net that made use of:
● Assessing the performance of your practice
● Making it easy to learn from errors
● Looking for system changes that will help prevent future errors
Culture change
A feature of cultural safety under safety net: cultural change that involves the leader considers themself as a member of the team.
Active leadership
A feature of cultural safety under safety net: cultural change that involves people knowing that their concerns will be openly received and treated with respect.
Psychological safety
A feature of cultural safety under safety net: cultural change that involves members being comfortable speaking about safety concerns with confidence that the organization will learn from problems and use them to improve the system.
Transparency
A feature of cultural safety under safety net: cultural change that involves people knowing that they will not be punished or blamed for system-based errors.
Fairness
T/F: Medication errors have the potential for adverse drug events/preventable adverse drug events/ameliorable ADEs.
T
T/F: Medication errors don’t result from problems in systems rather than exclusively from staff performance or environmental factors.
F
T/F: Medication errors are avoided if medication error prevention strategies are established.
T
T/F: Medication errors cannot be reduced by following the 6 rights of safe medication administration (right drug, right patient, right dose, right route, right time and right documentation.
F
