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Medication Errors

Medication errors are preventable events that can lead to inappropriate medication use and patient harm, contributing to 14% of drug-related deaths. Common causes include ambiguous labeling, illegible handwriting, and inadequate training, while types of errors encompass prescribing, omission, and monitoring errors. Pharmacists play a crucial role in preventing these errors through drug therapy monitoring, clarifying medication orders, and ensuring accurate dispensing.

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Elaine TFA
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6 views

Medication Errors

Medication errors are preventable events that can lead to inappropriate medication use and patient harm, contributing to 14% of drug-related deaths. Common causes include ambiguous labeling, illegible handwriting, and inadequate training, while types of errors encompass prescribing, omission, and monitoring errors. Pharmacists play a crucial role in preventing these errors through drug therapy monitoring, clarifying medication orders, and ensuring accurate dispensing.

Uploaded by

Elaine TFA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Medication Errors

Medication Errors

 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.
 Medication errors are associated with significant unexpected drug-
related morbidity and mortality.
 Errors in the medication-use process such as prescribing, dispensing,
administering, and monitoring are responsible for 14% of drug-related
deaths.
Causes of Medication Errors:

 Ambiguous strength designation on labels or packaging


 Drug product nomenclature (look-alike or sound-alike names, use of
lettered or numbered prefixes and suffixes in drug names)
EXAMPLES: DOBUTAMINE & DOPAMINE, DACTINOMYCIN, DAPTOMYCIN
 Equipment failure or malfunction
 Illegible handwriting
 Improper transcription (a written or printed version of something)
 Inaccurate dosage calculation
 Inadequately trained personnel
 Inappropriate use of abbreviations ( IU/IV, INSTEAD OF QD WRITE DAILY, QOD write every
other day, decimal mistakes)
 Labeling errors
 Excessive workload
Types and definition of medication
errors:
 Prescribing error:
Incorrect drug selection (based on indications, contraindications, known
allergies, existing drug therapy), dose dosage form, quantity, route,
concentration, rate of administration, or instructions for use of a drug
product ordered or authorized by prescriber; illegible prescription or
medication order that led to errors that reach the patient.
 Omission error:
Failure to administer an ordered dose to a patient before the next
scheduled dose.
Wrong-time error:
Administration of the medication outside of a predefined time interval from
scheduled administration time (each facility must establish the interval).

Unauthorized-drug error:
Administration of a medication not authorized by a legitimate prescriber for the
patient.

Improper-dose error:
Administration of a dose that is greater than or less than the amount ordered by
the prescriber, or administration of duplicate doses to the patient (i.e., one or more
dosage units from those that were ordered)

Wrong-dose form error:


Administration of a drug product in a different form than that ordered by the
prescriber

Wrong drug- preparation error:


Drug product incorrectly formulated or manipulated before administration
Wrong administration- technique error:
Inappropriate procedure or improper technique in administration of drug

Deteriorated-drug error:
Administration of a drug that has expired or for which the chemical or physical
dosage-form integrity has been compromised.

Monitoring error:
Failure to review a prescribed regimen for appropriateness and detection of
problems, or failure to use appropriate clinical or laboratory data for adequate
assessment of patient response to prescribed therapy.

Compliance error:
Inappropriate patient behavior regarding adherence to a prescribed medication
error.
Role of Pharmacist in preventing
medication errors:
 Participate in drug therapy monitoring and MUE activities to achieve
safe, effective, and rational drug use.
 Recommend and recognize appropriate drug therapy by staying
current with literature, consulting with other health-care
professionals,
and participating in continuing education programs.
 Be available to prescribers and other health-care professionals to
provide information about therapeutic drug regimens and correct
medication use.
Continued…

 Be familiar with the medication ordering system and drug distribution


policies and procedures to provide for the safe distribution of all
medications and supplies.
 Clarify confusing medication orders.
 Maintain an orderly work area and limit interruptions.
 Ensure accuracy of drug, labeling, packaging, quantity, dose, and
instructions. This may involve checking of technical staff and
automated
devices, self-checking, and double-checking others.
 Dispense medications in ready-to-administer forms whenever possible..
Continued…

 Use auxiliary labels that help in prevention of errors (e.g., shake well,
not for injection).
 Ensure delivery of medications to the patient-care area in a timely
fashion.
 Observe medication use in patient-care areas to ensure that dispensing
and storage procedures are followed to optimize patient safety.
 Counsel patients or caregivers on appropriate medication use.
 Review preprinted medication order forms and computerized
medication ordering screens
System for reporting errors:

 Each institution must have a system for reporting errors. The system
should be nonpunitive and focus on developing systems that minimize
recurrence. Institutional reporting techniques may include the following:
 Anonymous self-reports
 Incident reports—errors are written up as legal reports and satisfy JCAHO
requirements.
 Critical incident technique—observations and interviews of those involved in the
error are used to analyze and identify weaknesses in the system.
 Disguised observation—observers are placed among health-care professionals to
watch for errors.
 Institutions should also involve numerous types of health-care providers in
assessing and monitoring medication errors and in developing educational
and interventional programs.

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