Medication Erros 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 health care professional, patient or consumer. Such events may be. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”.
Medication Error
through lack of knowledge
knowledge-based errors
using a bad rule or misapplying a good rule
rule-based errors
called slips
action-based errors
called lapses
memory-based errors
no error; capacity to cause error
A
error, but did not reach the patient
B
error that reached the patient but unlikely to cause harm (omissions considered to reach the patient)
C
error that reached the patient and could have necessitated monitoring and/or intervention preclude harm
D
error that could have caused temporary harm
E
error that could have caused temporary harm requiring initial or prolonged hospitilization
F
error that could have resulted in permanent harm
G
error that could have necessitated intervention to sustain life
H
error that could have resulted in death
I
no example given
A and B
multivitamin was not ordered for admission
C
regular release metoprolol was ordered for patient instead of extended-release
D
blood pressure medication was inadvertently omitted from the orders
E
anticoagulant such as warfarin was ordered daily when the patient takes it every other day
F
immunosuppressant medication was unintentionally ordered at one-fourth the dose
G
anticonvulsant therapy was inadvertently omitted
H
beta-blocker was not reordered post-operatively
I
salbutamol inhaler was unintentionally removed from the list of orders
H
e-zinc drops was given instead of Cetirizine drops.
C
alteplase was given instead of tranexamic acid.
D
mefenamic acid was not prescribed after a tooth extraction.
E
a. wrong dose
b. wrong route
c. wrong patient
d. wrong time
e. wrong frequency
f. wrong drug
g. illegible or ambiguous prescription
h. prescribe a drug to a patient with an allergy
i. drug interaction
prescribing error
a. omit key information
b. re-writing doses
transcribing error
a. incorrect preparation of drug or infusion solution
b. dispense an expired drug
c. incorrect written information on drug label
d. equipment failures.
e labelling errors
f. wrong drug.
g. poor drug storage practice
h. drug dispensed too late
i. dspense non-standard drug concentration
dispensing error
a. wrong route
b. wrong dose
c. wrong time
d. incorrect frequency
e. wrong patient
f. drug not administered
g. double checking omissions
h. prepare incorrect infusant solution
i. non-compliance failure
administration error
The patient’s chemotherapy dosage is calculated based on an old weight so the dose is too low.
prescribing error
Dose, drug, route, frequency or patient information is omitted when the prescription is transcribed.
transcribing error
Poor quality sticky labels fall off syringes during transfer from pharmacy to the ward.
dispensing error
Vincristine or vinblastine administered intrathecally rather than intravenously
administration error
Intravenous vincristine is prescribed for intrathecal administration.
prescribing error
Ceftriaxone dispensed instead of clindamycin.
dispensing error
Pediatric patient who was recovering from brain tumour surgery is given a 650-mg dose
administration error
A drug is prescribed for patient A which is meant for patient B.
prescribing error
Four patients on a busy surgical ward receive their intravenous antibiotics 45±60 min late
administration error
Poor handwriting of the prescriber
prescribing error
A doctor prescribe a drug to which a patient has a known allergy
prescribing error
300 mg of morphine, prescribed to a terminally ill cancer patient, is given in error to the patient in an adjoining room of a nursing home
administration error
The doctor mistakenly writes a prescription for cyclophosphamide so that the combined 4-d dose is to be given in 1 d, instead of once daily over 4 d.
prescribing error
Mis-prescribed 10-fold digoxin dose for 3á2 kg newborn baby was given by a nurse even though hospital policy stated that only medical staff could administer this drug
administration error
