Medication Errors

Question 1

WHO definition of Medication error

Answer 1

A reduction in the probability of treatment being timely and effective, or an increase in the risk of harm relating to medicines and prescribing compared with generally accepted practice’’

Question 2

Medication error definition

Answer 2

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.

Question 3

Another medication error definition

Answer 3

A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’

Question 4

Prescribing fault meaning

Answer 4

A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’.

Question 5

Forms of prescribing faults

Answer 5

Irrational
Inappropriate
Ineffective prescribing
Underprescribing
Overprescribing.

Question 6

Prescription error meaning

Answer 6

Prescription error is a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription

Question 7

Normal features of a prescription

Answer 7

Identity of the recipient
Identity of the drug
Drug formulation
Dose
Route
Timing
Frequency
Duration of administration.

Question 8

Causes of medication error

Answer 8

• Lack of knowledge.
• Unclear or erroneous labeling of drug
• Misidentification of patient.
• Mental lapses.
• Verification errors.
• Errors committed by both experienced & inexperienced staff.

Question 9

What is an error?

Answer 9

When actions are intended but not performed

Question 10

What are mistakes?

Answer 10

Errors in planning actions

Question 11

Skill based errors - slips and lapses

Answer 11

Errors in executing correctly-planned actions

Question 12

What is a knowledge-based error?

Answer 12

Knowledge-based errors can be related to any type of knowledge, general, specific, or expert.

Question 13

Example of knowledge-based error

Answer 13

It is general knowledge that penicillins can cause allergic reactions; knowing that your patient is allergic to penicillin is specific knowledge; knowing that co-amoxiclav (augentin) contains penicillins is expert knowledge. Ignorance of any of these facts could lead to a knowledge-based error.

Question 14

What is a rule-based error?

Answer 14

Rule-based errors can further be categorized as the misapplication of a good rule or the failure to apply a good rule; and the application of a bad rule.

Question 15

What is an action-based error?

Answer 15

An action-based error is defined as ‘the performance of an action that was not what was intended’.

Question 16

Example of action-based error

Answer 16

A slip of the pen, when a doctor intends to write diltiazem but writes diazepam, is an example.

Question 17

What is a memory-based error?

Answer 17

Memory-based errors occur when something is forgotten; for example, giving penicillin, knowing the patient to be allergic, but forgetting.

Question 18

Types of medication error

Answer 18

Prescribing errors
Dispensing errors
Administration errors

Question 19

What are prescribing errors?

Answer 19

Prescribing errors include Incorrect drug selection for a patient, errors in quantity & indication e.g Prescribing contraindicated drug

Question 20

Factors contributing to prescribing errors

Answer 20

• Lack of knowledge of the prescribed drug, dose, patient details
• Illegible handwriting
• Inaccurate medication history taking
• Confusion with the drug name
• Inappropriate use of decimal points
• Use of abbreviations (e.g. AZT)
• Use of verbal orders

Question 21

Risk factors for prescribing errors

Answer 21

•Work environment & workload
•Miscommunication within team
•Physical & mental well being
•Lack of knowledge
•Inadequate training
•Low perceived importance of prescribing
Absence of self awareness of errors

Question 22

How to reduce prescribing errors?

Answer 22

• Electronic prescribing reduces errors due to illegible handwriting.
• Computerized physician order entry system eliminates need for transcription orders by nursing staff

Question 23

What are dispensing errors?

Answer 23

• Receipt of the prescription supply of a dispensed medicine to patient
• Occurs primarily with drugs having similar name or appearance

Question 24

Examples of dispensing errors

Answer 24

Potential dispensing errors include – wrong dose – wrong drug or – wrong patient

Question 25

How to reduce dispensing error

Answer 25

• Ensuring a safe dispensing procedure
• Separating drugs with similar name or appearance
• Unit dose medication dispensing
• Automated medication dispensing system
• Bar code medications for dispensing & administration (patient given barcoded wristband)

Question 26

Examples of administration errors

Answer 26

• Discrepancy between drug received by patient & drug therapy intended by prescriber
• Errors of omission - the drug is not administered
• Incorrect administration technique & administration of incorrect or expired preparations
• Deliberate violation of guidelines

Question 27

Contributing factors to administration error

Answer 27

• Failure to check patient’s identity prior to administration
• Environmental factors such a noise, interruptions, poor lighting
• Wrong calculation to determine the correct dose

Question 28

How to reduce administration errors

Answer 28

• Checking patient’s identity.
• Ensuring dosage calculations are cross checked independently by another health care professional before drug is administered
• Ensuring medication given at correct time
• Minimizing interruptions during drug rounds

Question 29

Classification of medication error

Answer 29

Memory-based
Knowledge-based
Action-based
Rule-based

Question 30

What are the classes of medication error?

Answer 30

Knowledge-based error
Rule-based error
Action-based error
Memory-based error