Prescribing Errors Flashcards
What is a medication error
Any preventable event that may cause or lead to inappropriate medication use or patient harm, while medication is in the control of the health care professional, patient or consumer
At what stage can a medication error occur
At any stage of the process involved in the delivery of medicines to a patient
Prescribing, dispensing, labelling, administration and even when the patient uses the medicines him/herself
What are the four most common drug groups associated with preventable drug-releated hospital admission
Antiplatelets
Diuretics
NSAIDs
Anticoagulants
When are healthcare professionals more likely to make errors
Inexperienced Inattentive Rushed Distracted Tired Depressed
Why do medication errors happen
Increase in numbers and variety of drugs Patients have co-morbidities Complexity of care process (multiple specialists, care settings, care delivery paths/journeys) Need for high risk medications Number of prescribers OTC usage
How does a prescribing error result
A clinically meaningful prescribing error occurs when, as a result of a prescribing decision or prescription writing process, there is an unintentional significant:
- Reduction in the probability of treatment being timely and effective or
- Increase in the risk of harm when compared with generally accepted practice
What are the two processes that can be involved in a prescribing error
Prescribing decision
Prescription writing
What is a prescribing fault
Failures in the process of deciding which drug to use and how
What is a prescribing error
Failures in the prescription writing process that result in wrong instructions about one or more of the normal features of a prescription
What type of prescription writing errors can occur
Wrong Patient Abbreviation Incomplete Rx Missing instructions Omission of signature Incorrect drug Illegible
What type of prescription decision errors can occur
CI to medication
Duplication
Allergy
Drug-drug interaction
What kind of prescription writing and decision errors can occur
Duration Omission Timing Frequency Route Dose Formulation No indication
What is a mistake
Errors that arise from poor planning or inadequate knowledge are characterized
What is a slip
Those that arise from imperfect execution of well-formulated plans when an erroneous act is committed
What is a lapse
When a correct act is omitted
What types of tasks are prone to error
Tasks that are unfamiliar to the operator or performed under pressure
Tasks that require the calculation of a dosage or dilution are especially susceptible to error
In what departments of the hospital are medication error rates higher
Paediatric
ICU
What are the 5 Rs
Right patient Right drug Right route Right time Right dose
What types of errors can occur
Medication omitted
Incomplete prescription
Incorrect dose
Incorrect frequency (correct total daily dose, incorrect total daily dose)
What type of incorrect doses can occur
Sub therapeutic
Super-therapeutic
When can errors occur
Admission Transcription of a new drug chart Discharge Remainder of inpatient stay While decanting
What us the 6th R
Right formulation
What drug properties should be though of when prescribing
Mechanism of action
Pharmacokinetics
ADRs, Interactions
Protocol
What should be considered before prescribing
The patient’s medication history
Other factors that might alter the benefits and risks of treatment
