M4

• Medication errors are a major problem
• In the USA, $17 billion - $37 billion is lost annually due to medication errors, from loss of income, disability and healthcare expenses
• At least 400,000 adverse drug events occur in hospitals
• Medication errors are not fully preventable
• Medication errors cause more deaths in a year than:
• Medication safety


  Totality of medication use to the patient
• Over 7000 preventable deaths occur each year due to medication errors
• 6 Aims of Medication Safety

  • Safety
  • Effectiveness
  • Patient-centeredness
  • Timeliness
  • Efficiency
  • Equitable
• Medication misadventures


  Medication hazards or incidents associated with indicated drug therapy resulting in harm
• Adverse Drug Reactions (ADR)

  Drug related problem that consists of an unexpected, unintended, undesired or excessive response to a drug that requires medical response or results in negative outcome at normal doses during normal use
• Adverse Drug Events (ADE)

  ADRs that result in an injury that is either preventable or not due to the use or lack of intended use of a drug
• ADR is not always a result of medication error
• Allergic reaction


  Result of immunologic sensitivity to drugs
• Idiosyncratic reaction


  Reaction to a medication that is unpredictable and unique to a particular person
• Allergic reactions and idiosyncratic reactions are considered ADRs, not side effects
• Side effects


  Expected and predictable reactions that require monitoring or adjustment in patient management
• Medication errors


  Any preventable event that may cause or lead to inappropriate medication use or patient harm
• Causes of medication errors

  • Lack of patient information
  • Lack of drug information
  • Lack of communication related to medication
  • Inadequate drug labeling, packaging
  • Lack of medication delivery device
  • Environmental factors
  • Inadequate staff competency and education
  • Lack of patient education
• Prescribing error


  Inappropriate or incorrect drug selection
• Dispensing error


  Incorrect drug issued, either as wrong drug, strength, or dosage form
• Administration error


  Caused by healthcare personnel
• Omission error


  Failure to administer an ordered dose to a patient before the next scheduled dose
• Wrong time error


  Administration of medication outside a predefined time interval from its scheduled administration time
• Unauthorized drug error


  Administration to the patient of medication not authorized by a legitimate prescriber
• Improper dose error


  Administration to the patient of a dose that is greater than or less than the amount ordered
• Wrong dosage form error


  Administration to the patient of a drug product in a different dosage form than ordered
• Wrong drug-preparation error


  Drug product incorrectly formulated or manipulated before administration
• Wrong administration-technique error


  Inappropriate procedure or improper technique in the administration of a drug
• Deteriorated drug error


  Administration of a drug that has expired or the physical/chemical integrity has been compromised
• Monitoring error


  Failure to monitor a prescribed regimen for efficacy and detection of problems, or use appropriate monitoring for adequate assessment of patient response
• Compliance error


  Inappropriate patient behavior regarding adherence to a prescribed medication regimen
• Categories of medication errors based on severity

  • Category A: Circumstances or events that have the potential to cause error
  • Category B: Error occurred but did not reach the patient
  • Category C: Error occurred but did not cause patient harm
  • Category D: Error occurred that resulted in the need for increased patient monitoring but no patient harm
  • Category E: Error occurred that resulted in the need for treatment or intervention and caused temporary patient harm
  • Category F: Error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm
  • Category G: Error occurred that resulted in permanent patient harm
  • Category H: Error occurred that resulted in a near-death event
  • Category I: Error occurred that resulted in patient death
• Other reasons for medication errors

  • BANDEM
  • DO NOT USE abbreviations
  • Use "U", "IU" for Unit, International unit
  • Use "MgSO4" for Magnesium sulfate
  • Use "MS" or "MSO4" for Morphine sulfate
  • Use "μg" for Microgram
  • Use "OS", "OD", "OU" for Left eye, right eye, both eyes
  • Use "AS", "AD", "AU" for Left ear, right ear, both ears
  • Use "QD" or "OD", "QOD" for Daily, Every other day
  • Use trailing zero (ex. 2.0mg), not lack of leading zero (ex. .2mg)
• Prevention of medication errors

  • Involve the patient in the medication process
  • Consumer-oriented medication resources
  • Access to patient information for healthcare providers
  • Better medication labeling
  • Improved health information technology
• Pharmacist's role in preventing medication errors

  • Medication literature for drug error information
  • Verification and accuracy of new prescription data
  • Monitoring errors and reporting them
  • Patient identities verified using bar codes
  • Educating patients on their medications
  • Patient involvement in the medication process
  • Electronic prescribing
  • Improvement of prescription filling technology
  • Patient monitoring
  • Medication reconciliation
• Medication reconciliation


  Process of resolving discrepancies by comparing what a patient has been taking in the past versus what the patient should be taking at the present