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.
