Systems Analysis,

Causes of Medication Errors,

and
Error-Prone Abbreviations
 Learning Objectives

• Describe the systems factors that play a

major role in medication errors
• Discuss the proximal causes of medication
errors
• Identify error-prone abbreviations and ways
to improve communication of ambiguous
medication orders
 Systems, Not People
• Medication errors are property of the
system as a whole rather than results of
the acts or omissions by the people in the
system
• Performance improvement requires
changing the system, not changing the
people
– Practitioners are sometimes held to an
unattainable standard—perfection
 Perspective
• Accepting a goal of a 99.9% success rate,
we’d have:
– 2 million documents lost every year by the IRS
– A major plane crash every 3 days
– 16,000 items lost every hour in the mail
– 37,000 errors every hour by automated teller
machines
– 107 erroneous medical procedures performed
every day
 Proximal Causes of
Medication Errors
• Lack of drug knowledge • Faulty dose checking
• Lack of patient • Infusion pump and
information parenteral delivery
• Rule violations problems
• Slips and memory • Inadequate patient
lapses monitoring
• Transcription errors
• Drug stocking and
• Faulty drug identity delivery problems
checking
• Faulty interaction with • Preparation errors
other services • Lack of standardization
Leape LL. JAMA 1995;274:35–43.
 Distribution of Medication
Errors by Proximal Cause

Lack of Drug
Knowledge 22%
Lack of Patient
Information 14%

Rule Violations
10%
Slips/Memory
Lapses 9%
Transcription
Errors 9%

0% 5% 10% 15% 20% 25%

Leape LL. JAMA 1995;274:35–43.

 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Causes of Errors Based on
Key System Elements

• Lack of information about the patient

• Lack of information about the drug
• Communication and teamwork failure
• Unclear, absent, or look-alike drug labels
and packages, and confusing or look-alike
or sound-alike drug names
• Unsafe drug standardization, storage, and
distribution
 Causes of Errors Based on
Key System Elements (continued)

• Nonstandard, flawed, or unsafe medication

delivery devices
• Environmental factors and staffing patterns
that do not support safety
• Inadequate staff orientation, ongoing
education, supervision, and competency
validation
 Causes of Errors Based on
Key System Elements (continued)

• Inadequate patient education about

medications and medication errors
• Lack of a supportive culture of safety,
failure to learn from mistakes, and failed or
absent error-reduction strategies, such as
redundancies
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Patient Information
• 18% of serious preventable adverse drug
events (ADEs) attributable to insufficient
information before prescribing, dispensing,
and administering
• 29% of prescribing errors alone attributable
to a lack of patient information
 Patient Information
• Lack of critical patient information
– Current laboratory values
– Height, weight
– Diagnoses
– Pregnancy, breastfeeding
– Allergies
– Other drug therapies
• Lack of interface between laboratory and
pharmacy systems
• Medication reconciliation
 Patient Information

• Ideally, essential information is obtained,

readily available in useful form, and
considered when prescribing, dispensing,
and administering medications
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Drug Information

• 35% of preventable ADEs attributable to

inadequate dissemination of drug information
• One in six ADEs caused by a combination of:
– Insufficient knowledge of drug doses
– Miscalculations
– Incorrect expression of measurement or drug
concentration
 Drug Information

• Lack of accessible or up-to-date references

• Lack of a tightly controlled formulary
• Failure to use standardized drug protocols
• Computer systems that fail to detect unsafe
orders
• Lack of clinical pharmacists in patient care
areas
• Handwritten medication administration
records
 Drug Information

• Ideally, essential drug information is

readily available in useful form to those
ordering, dispensing, and administering
medications
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Communication of Drug
Information

• Barriers that lead to ineffective communication

dynamics
• Unclear order communication
– Ambiguous or incomplete orders
• Illegible handwriting
• Look-alike and sound-alike drug names
• Verbal orders misspoken or misheard
 More Types of Failed
Communication
• Zeroes and decimal points
– Always use a “leading zero” (a zero before the
decimal point)
– Never use a “trailing zero” (a whole number followed
by a decimal point and a zero)
• Use of apothecary system instead of metric
system
• Poor design of computer-generated medication
administration records
• Dangerous abbreviations and dose designations
 Misinterpreted Physician’s
Prescriptions

• Study showed that medication errors

consequential to misinterpreted
physician’s prescriptions were the
second most prevalent and expensive
claims listed on 90,000 malpractice
claims filed over a 7-year period
Avoid Dangerous Abbreviations

• Letter “U” for unit

• “QD” or “qd” for daily
• “QOD” or “q.o.d.” for every other day
• IU (International Unit) may be mistaken for
IV (intravenous)
Look-Alike and Sound-Alike
Drug Names

Lamisil Lamictal
Taxol Taxotere
Vincristine Vinblastine
Amrinone Amiodarone
Ritonavir Retrovir
 Communication

• Ideally, methods of communicating drug

orders and other drug information are
standardized and automated to minimize
the risk of error
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Look-Alike Packaging
Sound-Alike Drug Names
 Drug Labels and Packaging

• Ideally, strategies are undertaken to

minimize the possibility of errors with
products that have similar or confusing
labels, packages, or drug names
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Drug Distribution Practices

• Unit-dose system
• Floor stock
• Computer-generated labels
• Automated dispensing equipment
• Drug storage
• Pharmacy access after hours
 Drug Standardization,
Storage, and Distribution

• Ideally, intravenous solutions, drug

concentrations, and administration times
are standardized whenever possible
• Unit-based floor stock is restricted
 Drug Standardization,
Storage, and Distribution
• Medications should be provided to patient
care units in a safe and secure manner
and available for administration within a
time frame that meets essential patient
needs
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Problems Related to
Drugs and Drug Devices
• Labeling and packaging
• Automated compounders
• Infusion pumps
 Medication Delivery Devices

• Ideally, the potential for human error is

mitigated through careful procurement,
maintenance, use, and standardization of
devices used to prepare and deliver
medications
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Problems With Environmental
Factors and Staffing Patterns

• Lack of space, crowded and disorganized

storage
• Poor lighting, excessive noise
• High patient acuity
• Deficient staffing, excessive workloads
 Environmental Factors and
Staffing Patterns

• Ideally, medications are prescribed,

transcribed, prepared, and administered in
a physical environment that offers
adequate space and lighting and allows
practitioners to remain focused on
medication use
 Environmental Factors and
Staffing Patterns

• The complement of qualified, well-rested

practitioners matches the clinical workload
without compromising patient safety
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Staff Competency and
Education

• Ideally, practitioners receive sufficient

orientation to medication use and
undergo baseline and annual
competency evaluation of knowledge
and skills related to safe medication
practices
 Staff Competency and
Education

• Practitioners involved in medication use

are provided with ongoing education
about medication error prevention and
the safe use of drugs that have the
greatest potential to cause harm if
misused
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Patient Education

• Problems
– Failure to adequately educate patients
– Lack of pharmacist involvement in direct
patient education
– Failure to provide patients with
understandable written instructions
– Lack of involving patients in check systems
– Not listening to patients when they express a
concern or question their therapy
 Patient Education

• Inform patient of drug names, purpose,

dose, side effects, and management
methods
• Suggest readings for patient
• Inform patient about right to ask questions
and expect answers
• Listen to what patient is saying and
provide follow-up!
 Patient Education

• Ideally, patients are included as active

partners in their care through education
about their medications and ways to avert
errors
 10 Key Elements of the
Medication System
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
 Culture Change

• Provide leadership
• Design job to:
– Avoid reliance on memory
– Promote simplification and standardization
• Promote effective team functioning
• Anticipate the unexpected
– Design for recovery
• Create a learning environment
 Quality Processes

• A nonpunitive, system-based approach to

error reduction is in place and supported by
management, senior administration, and
the board of trustees
 Accountability in Systems

• A nonpunitive, system-based approach to

error reduction does not diminish
accountability; rather, it redefines
accountability and directs it in a productive
and useful manner
 Quality Processes

• Ideally, practitioners are stimulated to detect

and report errors, and interdisciplinary
teams regularly analyze errors that have
occurred within the organization and in
other organizations for the purpose of
redesigning systems to best support safe
practitioner performance
 More on the Problem of
Error-Prone Abbreviations,
Symbols, and Dose Designations
 Problems With
Medical Notation
• Ambiguous medical notations are one
of the most common and preventable
causes of medication errors
• Drug names, dosage units, and
directions for use should be written
clearly to minimize confusion
 Consequences of Using
Error-Prone Abbreviations

• Misinterpretation may lead to mistakes

that result in patient harm
• Start of therapy may be delayed because
of time spent for clarification
 Implement “Do Not Use” List

• The Institute for Safe Medication Practices

(ISMP) and the Food and Drug Administration
recommend that ISMP’s list of error-prone
abbreviations be considered whenever medical
information is communicated
• To access the complete list, go to:
www.ismp.org/Tools/errorproneabbreviations.pdf
 Consider All Forms
of Communication
• Written orders
• Internal communications
• Telephone/verbal prescriptions
• Computer-generated labels
• Labels for drug storage bins
• Medication administration records
• Preprinted protocols/prescriptions
• Pharmacy and prescriber computer order
entry screens
 Short List of
Error-Prone Notations
• The following notations comprise The Joint Commission
“Do Not Use” list and should never be used:

Notation Reason Instead Use

U Mistaken for 0, 4, cc “unit”
IU Mistaken for IV or 10 “unit”
QD Mistaken for QID “daily”
 Short List of
Error-Prone Notations

Notation Reason Instead Use

QOD Mistaken for QID, QD “every other

day”
Trailing zero Decimal point missed “X mg”
(X.0 mg)
Naked decimal Decimal point missed “0.X mg”
point
(.X mg)
 Short List of
Error-Prone Notations
Notation Reason Instead Use

MS Can mean morphine “morphine sulfate”

sulfate or magnesium
sulfate

MSO4 and Can be confused “morphine sulfate”

MgSO4 with each other or “magnesium
sulfate”

cc Mistaken for U “mL”

 Short List of
Error-Prone Notations
Notation Reason Instead Use

Drug name Mistaken for other Complete

abbreviations drugs or notations drug name
(especially those
ending in “l”)

> or < Mistaken as “greater than”

opposite of intended or “less than”

μg Mistaken for mg “mcg”

 Short List of
Error-Prone Notations
Notation Reason Instead Use

@ Mistaken for 2 “at”

& Mistaken for 2 “and”

/ Mistaken for 1 “per” rather

than a slash
mark
+ Mistaken for 4 “and”
 Short List of
Error-Prone Notations
Notation Reason Instead Use

AD, AS, AU Mistaken for OD, OS, OU “right ear,”

“left ear,”
or “each ear”

OD, OS, OU Mistaken for AD, AS, AU “right eye,”

“left eye,”
or “each eye”

D/C, dc, d/c Misinterpreted as “discharge” or

“discontinued” when “discontinue”
followed by list of
medications
 Other Good Practices to
Avoid Misinterpretation

• Drug name abbreviations can easily be

confused
– Always write out complete drug name
• Apothecary units are unfamiliar to many
practitioners
– Always use metric units
 Example of Misinterpreted
Abbreviation

• Intended dose of 4 units in patient history

• Interpreted as 44 units
• “U” should be written out as “unit”
 Example of Misinterpreted
Abbreviation

• Intended dose of “.4 mg”

• Interpreted as 4 mg from medication order
• Should be written as “0.4 mg”
 Example of Misinterpreted
Abbreviation

• Intended “Potassium chloride QD” in

medication order
• Interpreted as QID
• Should be written as “daily”
 Example of Misinterpreted
Abbreviation

• Intended recommendation of “less than 10”

• Interpreted as 40
• Should be written out as “less than” not “<”
 Example of High-Risk
Abbreviation Use

• “QD” in advertisement
• Should be written out as “daily”
 Example of Error-Prone
Abbreviation in Medical Literature

• “U” in prominent professional journal article

• Should be written out as “unit”
Avoid Error-Prone Abbreviations
Even in Printed Materials

• Expressions may still be confused

• Perpetuates the impression that
abbreviations are acceptable
• Error-prone abbreviations may be copied
into written orders
 Recommendations for
Health Care Professionals
• Avoid ambiguous abbreviations in written orders,
computer-generated labels, medication administration
records, storage bins/shelf labels, and preprinted
protocols
• Work with computer software vendors to make changes in
electronic order entry programs
• Provide examples when educating staff on how using
error-prone abbreviations have led to serious patient harm
• Provide staff with ISMP’s list of error-prone abbreviations
• Introduce health care students to the list of error-prone
abbreviations