medication errors Flashcards
6Rs of Medication Safety
RIGHT DRUG
RIGHT DOSE
RIGHT DOSAGE FORM
RIGHT ROUTE
RIGHT TIME
RIGHT PATIENT
It is 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.
Medication Error
A medication error that took place but has been captured before reaching the patient.
Near Miss
FACTORS CONTRIBUTING TO MEDICATION ERROR
Human Related
System Related
Medication Related
Medication Related Errors
• look alike or sound alike medications
• multiple dosage forms and strengths
System Related Errors
• lack of communication
• poor workflow
• no proper policy or guideline
in place
• disorganized workspace
• inadequate tools to complete
work
• lack of supervision
Human Related Errors (Provider)
• over worked
• under trained
• competence
• distracted
• illness
• stress
Human Related Errors (Patient)
• health literacy level
• in a hurry
• patient compliance
• trust providers to not make mistakes
Types of Medication Errors
• PRESCRIBING ERROR
• DISPENSING ERROR
• ADMINISTRATION ERROR
• TRANSCRIPTION ERROR
• DOCUMENTATION ERROR
• INDENT ERROR
as a result of a prescribing decision or prescription writing process, there is an unintentional significant (1) reduction in the probability of treatment being timely and effective or (2) increase in the risk of harm when compared with generally accepted practice”.
Prescribing Error
Prescribing Errors include:
• Incorrect Prescription
• Illegible Handwriting
• Drug allergy not identified
• Irrational combinations
• Out of list abbreviations
Suppression of a drug previously used
Omission error
Addition of a drug not previously used
Commission error
Incorrect dose
Dosing error
Incorrect dose frequency
Frequency error
Incorrect pharmaceutical form
Pharmaceutical form error
A drug from one class is substituted for another drug from the same class not previously used
Substitution error
Two drugs from the same class are prescribed
Duplication error
It is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality
Dispensing error
Dispensing error includes:
• Dispensing incorrect medication, dosage strength, or dosage form
• Dosage miscalculations
• Failure to identify drug interactions or contraindications
Common causes of dispensing error includes:
• Work environment
• Outdated or incorrect drug references
• Sound Alike and Look Alike Drugs (SALADs)
This type of medication error involves a discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber.
Administration error
Administration error may include:
• Errors of omission
• Incorrect administration technique
• Administration of incorrect or expired medication
• Deliberate violation of guidelines
An error in the process of making an identical copy of prescription in the medical records
Transcription error
It involves inconsistencies between the documented medication and the actual medication that was given to the patient.
Documentation error
An error that occurs during the process of indenting, ordering of drugs.
Indent error
