MEDICATION ERROR

Medication Errors
"A medication error is any preventable event that may cause or lead to inappropriate medication use or
patient

• Any preventable event that may cause or lead to in inappropriate medication use or patient harm due
to :

Wrong patient

Wrong medication

Wrong dose

Wrong route

Wrong time

Wrong documentation
 Medication Process

Monitoring Prescribing

Administering Transcribing

Dispensing Indenting
 Types of Medication Errors
• Prescription error

• Transcription error

• Indenting error

• Dispensing error

• Administration error

• Monitoring error
 Error Factors often Arises in medication administration

Poor communication

Carelessness

Multiple interruptions

Stress

Lack of knowledge

working conditions
 Causes of Errors
Factors associated with health care professionals

• Physical problems ,Tired, unwell, stressed etc.

• Lack of protocols or policies

• Lack of training

• Verbal rather than written culture

• Time pressure & Staff turnover

• Poor communication with healthcare staffs

• Lack of support from other healthcare professionals

 Causes of Errors
Factors associated with patients

• Lack of patient awareness of medicines

• Patient characteristics (e.g., personality, literacy and language barriers)

• Complexity of clinical case, including multiple health conditions,

polypharmacy and high-risk medications
 Causes of Errors
Factors associated with the work environment

• Workload and time pressures

• Distractions and interruptions (by both primary care staff and patients)

• Lack of standardized protocols and procedures

• Insufficient resources

• Issues with the physical work environment (e.g., lighting,temperature and

ventilation)
 Causes of Errors
Factors associated with medicines

• Naming of medicines

• Labelling and packaging

• Storage of medicine
 High Risk Areas for Medication Errors
• High alert medications

• High risk patients ((Pregnant, Elderly, HIV, Transplant Patients,

• Verbal orders
Anticoagulants, Pediatric Patients, Psych Patients)
• Abbreviations
• High risk diseases
• Look-alike drugs
• Infusion pumps (High Risk Medications, Incorrect Pump

Programming, Calculation / Concentration Errors, Wrong

Medication)
Prominent reasons enhancing Medication Error
 Look Alike & Sound Alike drugs

 Non compliance in Drug Standard Timing

 Units while prescribing drugs

 Prohibited Abbreviations

 Illegibility in prescription

 Unavailable Drug Information

 Independent Cross Checking

 High Risk Medications

 Medication Reconciliation and its documentation

 Medication Errors : High Alert Medications
 Chemotherapeutic drugs

 Potassium Chloride

 Opiates and narcotics

 Insulin and oral hypoglycemic agents

 Anticoagulants (Heparin)

 Antihypertensive agents

 Psychiatric medication

 Anticonvulsants

 Cardiac drugs
 Analysis of Administration Error
COMMUNICATION GAP

New joined staff

Escalation not done

Lack of monitoring and supervisory mechanism from the TL/In charge for costly medicines

Administer the medication at the wrong time

Lack of drug information for the nurses

Patient file not taken to the bedside during administration.

Instead of half tablet, full tablet administered

Cross checking of prescribed dose before administration

Wrong Initial time

Handover was not taking without checking the medication

Staff nurse did not cross check the file before hand over

Documented before administration leads to missed dose

0 10 20 30 40
Case Study
 Accidental administration of epinephrine instead of midazolam
A 50-year-old women who was accidentally administered epinephrine instead of midazolam
during colonoscopy preparation.

The patient originally presented to the hospital with a history of abdominal pain and altered
bowel habits. A colonoscopy was scheduled following administration of what was believed to
be midazolam 5 mg.

She then started to complain of chest tightness, difficulty breathing, and generalized tremors. It
was soon discovered that a medication error occurred and the patient was instead administration
0.25 mg of epinephrine instead of midazolam. The procedure was postponed for several days
until the patient recovered.
 A root cause of the error revealed that the epinephrine ampule was mistakenly

placed in the box with the midazolam in the pharmacy following an instance

where a previous patient did not require the medication.

 Ampules of both medications were similar in size, shape, and color. As a result,

the hospital initiated new procedures to ensure regular reviews of drug containers

and their contents and double checking medication names before administration.
Unintentional administration of insulin instead of influenza vaccine

5 adult patients unintentionally received insulin instead of the influenza vaccine.

The mix-up occurred at a public school clinic in Missouri and was discovered

following an investigation from the government. Officials learned that a school

nurse inadvertently administered Humalog U-100 insulin instead of the influenza

vaccine. Acute hypoglycemia was reported in all 5 patients who received the

insulin with varying degrees of symptoms.

 After the first 2 patients complained of sweating and lightheadedness, the
nurse reported the incidents to the supervising nurse, but did not stop
administering vaccines. Two later patients would require hospitalization
for their symptoms, one of which was documented to have a blood glucose
level of 23 mg/dL.

 The investigation revealed that the influenza vaccine vial was kept in the
nurse’s office refrigerator along with a 10 mL vial of Humaog U-100
insulin; they were found to not be stored in separate, labeled containers or
bins.
 MEDICATION ERROR ANALYSIS
MANPOWER DOCUMENTATION COMMUNICATION

New Nursing staff

Documented before Hand Over communication was
Joined
administration not proper

Wrong transcription Communication Gap between

Shortage of doctors
doctors and Nursing ; Nursing ,
No Documentation Pharmacist and Doctors

Shortage of Pharmacist Wrong documentation

Escalation not happen

Medication Error
Lack of knowledge & Staffs untrained on
Medication administration Incomplete Prescription
Infrequent audits
Doctors are not trained on No over sight by Nursing
medication reconciliation Illegible handwriting
TL

Staffs not sensitised about No over sight of Doctors notes Special instruction was not
medication error written

Cross checking was not

Pharmacist are not happen
trained

MONITORING
PRESCRIPTION
TRAINING
 Ways to Prevent Medication Errors

Follow and practice “ Rights of Drug” administration, the ways to prevent these errors are:

 Don’t administer any drug without a doctor’s order.

 Always check the label to identify a drug. Don’t rely on the drugs color, shape, or location

in the medication case.

 Check the label against the doctors order and the patient’s medication administration record

(MAR) two times: when obtaining the drug, when preparing the dose.
 If you have any doubts about the drug you are giving, call the doctor
 Check expiration dates, and return out dated drugs to the pharmacy.
 Ask senior nurse to double check your dosage calculations.
 Don’t give drugs another nurse has prepared.
 The nurse should have verified the dosage before giving the drug-and she should to
followed a basic administration rule, “If you don’t know a drug and it’s dosage, don’t give
it until you find out
 Don’t try to interpret illegible handwriting even in ask the physician.
 Identify the patient by his ID band- don’t just ask his name or check his bed number.
 Use appropriate documentation on the MAR (Medication Administration record) helped to
prevent errors.
Educating health care providers and patients
 Educating primary care providers about common causes of medication errors
 Providing simple tools to assist primary care providers in safe medication prescribing and use process
 Considering how patients can be actively involved in medicine management
 Providing patient engagement tools to address non-adherence

Implementing medication reviews and reconciliation

 Ensuring that pharmacists actively review prescriptions
 Encouraging and supporting use of medication reconciliation by clinicians

Using computerized systems

 Computerized provider order entry with decision support may be particularly effective when
targeted at a limited number of potentially inappropriate medications and when designed to reduce
the alert burden by focusing on clinically-relevant warnings.