LEC

• Medication Misadventure


  An iatrogenic hazard or incident that is an inherent risk when medication therapy is indicated, is created through either omission or commission by the administration of a medicine or medicines during which a patient may be harmed, with effects ranging from mild discomfort to fatality, whose outcome may or may not be independent of the preexisting pathology or disease process, may be attributable to error (human or system, or both), immunologic response, or idiosyncratic response, and is always unexpected or undesirable to the patient and the health professional
• Adverse Drug Events (ADEs)

  Any injury caused by a medicine, encompassing all ADRs, including allergic and idiosyncratic reactions, as well as Medication Errors that result in harm to a patient
• 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
• Types of Medication Errors


  • Prescribing
  • Order communication
  • Product labeling, packaging, and nomenclature
  • Compounding
  • Dispensing
  • Distribution
  • Administration
  • Education
  • Monitoring
  • Use
• Medication Errors


  • They are preventable
  • They can be caused by errors in the planning (deciding what to do—which drug and/or what dose) or execution stages (completing the task that was decided on—administering the drug to the wrong patient)
  • They include errors of omission (missed dose or appropriate medication not prescribed) or commission (wrong drug given)
  • They may or may not cause patient harm
• The NCCMERP Index for Categorizing Medication Errors provides a standard taxonomy of medication errors to be used in combination with systems analysis in recording and tracking of medication errors
• NCCMERP Patient Outcome Categories

  • No Error
  • Error, No Harm
  • Error, Harm
  • Error, Death
• Types of Medication Errors

  • Dose Omission
  • Improper Dose
  • Wrong Strength/Concentration
  • Wrong Drug
  • Wrong Dosage Form
  • Wrong Technique
  • Wrong Route of Administration
  • Wrong Rate
  • Wrong Duration
  • Wrong Time
  • Wrong Patient
  • Monitoring Error
  • Deteriorated Drug Error
  • Others
• Causes of Medication Errors


  • Communication (Verbal miscommunication, Written miscommunication)
  • Name Confusion (Proprietary (Trade) Name Confusion, Established (Generic) Name Confusion)
  • Labeling (Immediate Container Labels of Product, Labels of Dispensed Product, Carton Labeling of Product, Package Insert, Electronic Reference Material, Printed Reference Material, Advertising)
  • Human Factors (Knowledge Deficit, Performance Deficit, Miscalculation of Dosage or Infusion Rate, Computer Error, Error in Stocking/Restocking/Cart Filling, Drug Preparation Error, Transcription Error, Stress, Fatigue/Lack of Sleep, Confrontational or intimidating behavior)
• Contributing Factors to Medication Errors

  • 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
• Other Classifications of Medication Errors

  • Prescribing Error
  • Transcribing Error
  • Preparing Error
  • Dispensing Error
  • Administering to patient Error
  • Monitoring Error
• Prescribing


  Done by the Doctor, and includes failures to alter drug therapy in the face of altered physiology, disregard for a patient's history of allergy, prescribing an inappropriate medication, poor communication, lack of awareness of best practice recommendations, inappropriate duration of therapy, incorrect dosage or frequency calculations, illegible writing, inadequate monitoring or follow-up, discontinuity of pre-hospital and post-hospital medications, and transcription duplications and omissions in complex hospital medication charts
• Types of medication-related problems

  • Prescribing
  • Transcribing
  • Dispensing
  • Administration
  • Monitoring
• Compliance


  The extent to which a person's behavior coincides with the medical advice given. Patient is passive and just follows what the doctor advises.
• Adherence


  The extent to which the patient's behavior matches agreed recommendations from the prescriber. Patient is active and involved in the regimen.
• Prescribing


  • Done by the Doctor
  • 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
  • Poor communication with the patient &/or other members of the health team
• Transcribing


  • 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
• Concordance


  An agreement reached after negotiation between a patient and health care professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken. There is deep communication, mutual understanding and decision-making with the patient and the physician regarding the regimen.
• Helping patients Manage Therapeutic Regimens are the tips or strategies that can be employed to motivate the patient to be adherent or compliant to their therapies or regimens
• Rate of Adherence


  • The exact rate of adherence to medication regimens varies from study to study
  • Adherence rates are well below 100%, with the consensus being that adherence rates for long-term therapies tend to be about 50%
  • Indirect methods (subjective) like interviewing the patient or caregiver
  • Direct methods (objective) like using biomarkers or laboratory testing
• Dispensing


  • 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
  • Failure to understand doctors prescription (especially if handwritten)
  • Fails to ask if medication record is complete
  • Fails to check prescription against allergy history, existing drugs, possible interactions, etc
  • Dispenses wrong drug, wrong abbreviation, wrong dosage forms or wrong dose
  • Wrong patient
  • Wrong instructions, or wrong label
  • Poor communication with the patient &/or other members of the health team
• Cost of Nonadherence


  • Negative effects on patient health which can result in increased emergency room and physician visits, hospitalizations, disability, premature death, and decreased productivity in the workplace
  • Economic impact
• Administration


  • Wrong patient
  • Wrong drug
  • Wrong dose (problem with calculations)
  • Wrong route of administration
  • Wrong time
  • Administration not documented
  • Given twice
  • Poor patient communication
  • Inadequate monitoring or follow-up
• Monitoring


  • Patients are not monitored appropriately either before or after they have received a drug
  • Adequate blood tests (baseline and ongoing) are not performed to assess the patient's response
• Reasons for Poor or Nonadherence


  • Patients: Perception of medications, fear of taking medications, relying too heavily on medications
  • Healthcare providers: Lack of communication
  • Healthcare delivery system: Lack of insurance coverage, access to medications, economic concerns
• Unintentional Nonadherence


  Forgetting to take the medicine due to reasons like being busy
• Prescribing error - Inappropriate drug

  • Humulin R was ordered but the patient is using Humalog
  • KCl Elixir was ordered to a pregnant woman
• Intentional Nonadherence


  Skipping doses due to uncomfortable side effects or not taking medication before going to a party
• Prescribing error - Inappropriate dose

  • Co-amoxiclav susp 312.5 mg/5mL TID was ordered to a 13 Kg patient
  • Codeine syrup 30 mL BID was ordered
• Prescribing error - Inappropriate route

  • Ketoprofen (Orudis) IV was ordered as IV push
• Prescribing error - Inappropriate dosage form

  • Potassium Chloride 750mg durule BID was ordered per ngt but it should not be crushed or chewed
• Do not assume that physicians have already discussed the medications, patients understand all information provided, if patients understand what is required they will be able to take the medication correctly, when patients do not take their medications correctly that they "don't care", "aren't motivated", "lack intelligence", "can't remember", once patients start taking their medications correctly they will continue to do so in the future, physicians routinely monitor patient medication use, if patients are having problems they will ask direct questions or volunteer information
• Prescribing error - Allergy not noted

  • Patient is allergic to Penicillin, but there was an order of Ampicillin Sulbactam
• Prescribing error - Fluid restriction not noted

  • A patient with Congestive Heart Failure has an order of D5W250mL + 400mg Dopamine at 10 mcg/kg/min
• Techniques to Improve Patient Understanding

  • Emphasize key points, give reasons for key advice, give definite, concrete, explicit instructions, provide key information at the beginning and end of the interaction, supplement and reinforce spoken words with written instructions, assess the patient's ability to read and understand key written instructions, end the encounter by taking feedback
• Techniques to Establish New Behaviors

  • Tailoring of regimens, providing appropriate adherence aids, suggesting ways to self-monitor, monitoring medication use, making proper referrals
• Techniques to Facilitate Behavior Change

  • Establish new habits, change old habits, stop existing habits
• Theoretical Foundations Supporting Behavior Change

  • Willingness (amount of discrepancy patients perceive between current health status and goals), Perceived Ability (amount of self-confidence patients feel in their ability to initiate and maintain behavioral change), Readiness (how high a priority is given to these behavioral changes)
  • Empathic Understanding (facilitates the patient's own problem-solving ability, frees patients from the fear that they are being judged because of their behavior)
• Stages of Change


  • Precontemplation, Contemplation, Preparation/Determination, Action/Willpower, Maintenance, Relapse
• Precontemplation


  Not willing to change, not ready to change, don't know that there is a problem, not recognizing that there is a problem