Unit 1 2nd shifting lec

• Medication Misadventure


  An iatrogenic hazard or incident that is an inherent risk when medication therapy is indicated, created through either omission or commission by the administration of medicine, and may harm a patient with effects ranging from mild discomfort to fatality, with outcomes independent of preexisting pathology or disease process
• Medication Misadventure


  An iatrogenic hazard or incident that may be attributable to error (human or system, or both), immunologic response, or idiosyncratic response, always unexpected or undesirable to the patient and health professional
• Medication use process

  Many opportunities for unexpected adverse events, described as medication misadventures, includes medication errors, adverse drug events (ADEs), and adverse drug reactions (ADRs)
• Adverse Drug Events

  • Noxious and unintended outcomes experienced during or after medication treatment
• 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


  Preventable events related to professional practice, health care products, procedures, and systems, including errors in planning or execution stages, errors of omission or commission, may or may not cause patient harm
• NCCMERP Taxonomy of Medication Errors

  Standard taxonomy used in combination with systems analysis for recording and tracking medication errors, used in the Medication Error Reporting System, information should be collected and reported promptly, select the highest level severity in patient outcome category
• NCCMERP Taxonomy of Medication Errors - Type of Error

  • Dose Omission
  • Improper Dose
  • Wrong Strength/Concentration
  • Wrong Drug
  • Wrong Dosage Form
  • Wrong Technique (includes inappropriate crushing of tablets)
  • Wrong Route of Administration
  • Wrong Rate
  • Wrong Duration
  • Wrong Time
  • Wrong Patient
  • Monitoring Error
  • Deteriorated Drug Error
  • Others
• NCCMERP Taxonomy of Medication Errors - Causes of Error - Communication

  • Verbal miscommunication
  • Written miscommunication (Illegible handwriting, Abbreviations, Non-metric units of measurement, Trailing Zero, Leading Zero, Decimal Point, Misread or Didn't Read, Misinterpretation of the order)
• NCCMERP Taxonomy of Medication Errors - Causes of Error - Name Confusion

  • Proprietary (Trade) Name Confusion
  • Established (Generic) Name Confusion
• NCCMERP Taxonomy of Medication Errors - Causes of Error - Labeling

  • Immediate Container Labels of Product - Manufacturer, Distributor or Repackager
  • Labels of Dispensed Product – Practitioner
  • Carton Labeling of Product - Manufacturer, Distributor or Repackager
  • Package Insert
  • Electron
• Causes of Error

  • Name Confusion
  • Labeling
  • Human Factors
• NCCMERP TAXONOMY OF MEDICATION ERRORS

  • Immediate Container Labels of Product - Manufacturer, Distributor or Repackager
  • Labels of Dispensed Product – Practitioner
  • Carton Labeling of Product - Manufacturer, Distributor or Repackager
  • Package Insert
  • Electronic Reference Material
  • Printed Reference Material
  • Advertising
  • Knowledge Deficit
  • Performance Deficit
  • Miscalculation of Dosage or Infusion Rate
  • Computer Error
  • Error in Stocking/Restocking/Cart Filling
  • Drug Preparation Error
  • Transcription Error
  • Stress (high volume workload, etc.)
  • Fatigue/Lack of Sleep
  • Confrontational or intimidating behavior
  • Lighting
  • Noise Level
  • Frequent Interruptions and distractions
  • Training
  • Staffing
  • Lack of availability of health care professional
  • Assignment or placement of a health care provider or inexperienced personnel
  • System for Covering Patient Care
  • Policies and procedures
  • Communication systems between health care practitioners
  • Patient counseling
  • Floor Stock
  • Pre-printed medication orders
  • Others
  • Prescribing Error
  • Transcribing Error
  • Preparing Error
  • Dispensing Error
  • Administering to patient Error (including verifying medication)
  • Monitoring Error
• Contributing Factors

  • System for Covering Patient Care
  • Policies and procedures
  • Communication systems between health care practitioners
  • Patient counseling
  • Floor Stock
  • Pre-printed medication orders
  • Others
• OTHER CLASSIFICATIONS OF MEDICATION ERRORS

  • Prescribing Error
  • Transcribing Error
  • Preparing Error
  • Dispensing Error
  • Administering to patient Error (including verifying medication)
  • Monitoring Error
• THE MEDICATION PATHWAY


  • Prescribing - Doctor
  • Transcribing
  • Dispensing - Pharmacist
  • Administration - Nurse
  • Monitoring
• Failure to alter drug therapy in the face of altered physiology such as renal or liver impairment
• Disregard for a patient’s history of allergy to the same medication class
• Prescribing an inappropriate medication for a particular indication
• Prescription of the wrong drug name, wrong abbreviation or inappropriate dosage forms
• Poor communication with the patient &/or other members of the health team
• Lack of awareness of best practice recommendations
• Inappropriate duration of therapy
• Incorrect dosage or frequency calculations
• Illegible writing
• Inadequate monitoring or follow-up. Failure to monitor for side effects and serum drug level
• Discontinuity of pre-hospital and post-hospital medications
• Transcription duplications and omissions in complex hospital medication charts
• Wrong generic name was transcribed in the patient chart
• Wrong dose was entered/encoded in the Hospital Information System
• Wrong dosage form was entered in the request form
• Wrong prescription for discharge medications
• Wrong computation of amount or volume of ingredients
• Incorrect reconstitution or dilution of medicines
• Inappropriate manner/process of mixing medications
• Inappropriate container
• Wrong label
• Failure to check expiration date of ingredients
• Inappropriate storage of final product
• Failure to check compatibility of components of the preparation