23 Medication Errors Robert Cisneros 1. MEDICATION ERROR PROBLEM A. The 2000 Institute of Medicine (10M) = oo “ report To Err Is He th iaedicing to hetighal steak eee juman brought the problem of errors 1. Anestimated 44,000—98,000 deaths per year are caused by medical errors. Of those deaths, approximately 7,000 are the result of medication errors, 2. A call to action was given to improve patient safety. 5. ey years, tragic medication errors have focused attention on concerns regarding patient safety. 1, A chemotherapy mix up at a major cancer center resulted in the death of a patient from a fourfold overdose daily for 4 days. 2. A child accidentally received an intravenous rather than intramuscular dose of long-acting penicillin and died. 3. A compounding error resulted in death of a child who received a tricyclic antidepressant at a dose 10 times greater than the dose prescribed by physician. Il. ERROR DEFINITION. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines a medication error as follows: “A medication error is 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." |. TYPES OF ERRORS. The following categories of errors have been used in numerous research studies.> ‘A. Wrong drug error. A drug that was not ordered for a patient was administered —for example, a patient accidentally received furosemide 40 mg orally. Possible causes: The pharmacist accidentally filled the patient's prescription for an antibiotic with furosemide; the pharmacist reached for the wrong bottle on the shelf and did not check the label carefully enough. . Extra dose error. A patient receives more doses of a drug than were ordered—for example, a patient was supposed to receive a medication with breakfast for 3 days but received it for 5 days. Possible cause: The patient’s nurse was confused by the medication directions. C. Omission error. A dose of a drug was not administered as ordered but was skipped—for example, a patient was supposed to receive digoxin 0.25 mg orally in the morning but did not recewve the dose. Possible cause: The patient’s nurse was so busy that he or she forgot to administer the dose.492 Chapter 23 I! D jose of a medici D. Wrong dose or wrong strength error. Either the wrong dose of ine or the strength is administered —for ‘example, the patient was suppose to receive warfarin 0.5 ™ but received warfarin 5 Mg instead. Possible aera i aitlagiee ee the label; the Fi insteae in .5 mg.” Another exat Jatient was supp physician wrote the order as “warfarih © TR, cu, possible cause: The pharmacist took the 5% but was given timolol 0. rece duct of helt, ntused by the concentrations. wrong product off of the s edication by a route that was not ordered ror example, a patient was supposed °0 "eee prochlorperazine 10 Tre drug was administered intravenously Possible causes: The nurse mis physician mistakenly wrote “IV” instead of “IM E. Wrong route error. A patient receives dose of am by the physicia intramuscularly read the orders; the ‘of medication at the time at which it ent docmple, a hospitalized patient with diabetes is scheduled to ipaione breaklast (at 7:00 4.x.) but the dose is given 2 ‘and could not give dose on time, F. Wrong time error. A patient does not receive dose was t0 be administered— mreeive a dose of insulin immediately rece preakiast. Possible cause: The nurse was Busy fedicine in a dosage form that was, eives a dose of m ‘ordered for a patient who form error. A patient rec G. Wrong dosage Wrong stjed-for example, nicotinic acid 500 mg tablets were an ed 500 mg slow-release capsules. Possible cause: The pharmacist fused by the label instead receives ni did not carefully check the product or was con! y of the into any of the other categories. H. Other. Errors that do not fit into an} IV. COMMON ERROR HAZARDS s and symbols have been associ- te for Safe Medication Practices int Commission on Accreditation fety/DoNot confus- merous common abbreviation ilable from the Insti tionslist.pdf and the Joi jointcommission.org/PatientSat red to avoid using the potentially ‘A. Dangerous abbreviations. Nu ated with errors. Detailed lists are ava (ISMP) at www.ismp.org/Tools/abbrevia of lealthcare Organizations JCAHO) at http://www. UseLis, JCAHO’s accredited organizations are requit ing abbreviations on its "Do Not Use” list. 4. U, IU: unit(). The letter U can easily be misinterpretes serious harm has occurred with insulin and heparin as @ result of this confusion. For example, a patient received 66 units of insulin instead of 6 units. The order, which was written for "6U"" of regular insulin was misread as 66. The word units should be written out in full. 2. QD, QD., qd, qd. (daily). These common abbreviations have been misinterpreted a5 “Q1D" of “rqtd” Four times daly) resulting in overdoses. The word daily should be written out in ful 3. Q.0.D, QOD, qod (every other day). These c preted as QID (four times daily), resulting in over be written out completely. 4. Trailing zero. When a dose is ordered xd as a number (e.g,, 0 oF 4), and fe been misinter- -ommon abbreviations hav her day should doses. The words every ot and followed with a decimal point and a 20, such as 2.0 mg or 25.0 mg, errors can occur. The decimal point may be ‘missed and an overdose can occur. For example, warfarin 2.0 mg may be misinterpreted as 20 mg. Trailing Ze"0s Should be avoided, and the dose written without the additional zero—for example, warfarin 2 mg (instead of 2.0 mg). xin, Often the 5. Lack of leading zero. A drug’s dose may be less than 1 mg, such as for digo dose 's written without a leading zero: digoxin .25 mg instead of digoxin 0.25 mB. Errors have occurred because the decimal point is missed—for example, warfarin °° may Be interpreted as warfarin 5 mg. Leading zeroes should be included, so the dose is written 3 digoxin 0.25 mg or warfarin 0.5 mg. 7 MS, MSO, (morphine sulfate), MgSO, (magnesium sulfate). T sulfate and magnesium sulfate are quite similar and can be con morphine sulfate and magnesium sulfate be written in out in full. he abbrevi fused. It is recommnMedication Errors 493 B. Other confusing symbols, abbreviati abbreviations that should be mex} ations: There are numerous other hazardous symbols and Esh ‘d with caution when writing prescri d full examined when filling prescriptions, Examples include helen orders and carefully 1, cc. Stands for cubic centimeters and is often used instead of mL. This has been misinterpreted as a 0 (zero); use mL. 2 ms. Used for micrograms—for example, levothyroxine 250 jg daily. The abbreviation has been mistaken for mg, and overdoses have occurred; bette! mi to write out the , curred; better z etter to use mcg or 3. <, >. Symbols for less than (<) and greater than (>) have been mistaken for each other or misinterpreted as numbers. Better to write out the words less than or greater than. 4. HCT. This abbreviation for “hydrocortisone” zide. Better to write the word out completely, 5. HCI. The abbreviation for “hydrochloric acid” has been misinterpreted as KCI (potassium chloride). Better to write out the words completely. has been misinterpreted as hydrochlorothia- C. Sound-a-like or look-a-like drug names. A detailed list of confusing drug names can be found in the 2004 United States Pharmacopeia publication “USP Quality Review’ (www.usp.org/ pdf/EN/patientSafety/qr792004-04-01 pdf). Another list is available from ISMP (www.ismp.org/ Tools/confuseddrugnames.pdf). 1, Examples include the following: a. Amitriptyline and aminophylline b. Cisplatin and carboplatin ¢. K-Dur and Cardura 2. Toavoid these problems, the ISMP offers several suggestions, including the use of computer- ized reminders, name-alert stickers, and independent checks; opening the bottle in front of the patient, who can confirm the appearance; and reporting errors. D. High-risk drugs. Certain potent drugs have been implicated in many serious and tragic medica- tion errors. These have been called high-risk or high-alert drugs. A list of such medications can be found at www.ismp.org/Tools/highalertmedications.pdf. Examples include the following: 1. Blood-modifying agents such as heparin and warfarin. Errors have resulted in serious injury or death from hemorrhaging as a result of overdose (patient receiving 10 mg instead of 1 mg) or from blood clots as a result of underdose (patient receiving 0.5 mg instead of 5 mg). 2. Narcotics and sedatives. Central nervous system depression and respiratory arrest have resulted from errors with these drugs, such as diazepam 25 mg given intravenously instead of 2.5 mg. 3. Neuromuscular paralyzing agents such as succinylcholine and vecuronium. Accidental use or inadvertent use before adequate ventilation procedures were started have resulted in respiratory arrest and death. 4. Chemotherapy drugs. These drugs are associated with potent adverse effects, affecting numerous body systems, such as the immune, neurologic, and clotting systems. Deaths have occurred as a result of errors with these products. For example, vincristine was acciden- tally given to a child instead of vinblastine, resulting in death. Confusion over the dosing of cyclophosphamide resulted in a fatal fourfold overdose V. SEVERAL SAFETY TECHNIQUES OBSERVED IN COMMUNITY PHARMACIES* A. Keep work procedures organized and simplified. B. Don’t work on several prescriptions at once, just one at a time.494 Chapter 23 VC C. Manage interruptions, don’t be pressured to rush D. Smell check. E, Bar code check. F. Use a magnifying glass when needed. G. Enhance the design of the facility. VI. ROOT CAUSE ANALYSIS (RCA). This is a structured process for identifying direct and indirect factors that contributed to a medication error. A framework for conducting an RCA is avallsoe at htip/www jointcommission.org/SentinelEvents. See “Framework For Conducting a Root Came Analysis.” ‘A, Important questions to ask: 1. What happened and why? 2. What were the contributing factors? a. Age? Hours worked? Staffing? b. Workload? Stress? Confusing names? Location on shelf? . Inadequate information? Communication? d. Inadequate equipment? €. Workplace atmosphere conducive to safety? f. Inadequate training of pharmacist or technician? B. Latent defect. A weakness in a system that does not immediately result in an error but, under the right set of circumstances, can contribute to a mistake. For example: 1. Stocking look-alike or sound-alike drugs next to each other, contributit incorrectly filling a prescription. toa pharmacist 2. Inadequate training of employees, contributing to an error in which an automated dispen- sing machine was used improperly and a patient received the wrong medication. VI. NATIONAL SAFETY EFFORTS A. JCAHO’s National Patient Safety Goals for Accredited Organizations can be found at hitp:/ www jointcommission org/PatientSafety/NationalPatientSafetyGoals/. Hospital goals include: 1. Improve the accuracy of patient identification. Have two means of identifying the patient other than room number. 2. Improve communication among caregivers. Verify and read back telephone and oral orders 3. Create a lst of “do not use” abbreviations. Standardize the abbreviations used, and prohibit the use of those that are prone to confusion and misinterpretation, 4, Improve the safe use of medicines. ‘ a. Limit the number of different concentrations available per drug product; standardize. b. Develop methods of identifying and reviewing sound-alike and look-alike drugs, Pre venting errors with them. €. All medications and containers should be properly labeled. 5. Reduce the risk of infections. a. Comply with all Centers for for hand washing and hygiene. b. Thoroughly investigate all serious adverse events and deaths associated with infection acquired in a healthcare setting. 6. Keep accurate patient medication records and histories throughout the continuum of oe a. Ensure that a patient’s medication records are complete and accurate when he oF is referred or transferred within or between organizations. -ase Control and Prevention (CDC) recommendationsMedication Errors. 498 ; U MEDI SP MEDICATION ERRORS REPORTING PROGRAM nted in cooperat 'n cooperation with the Institute for Safe Medication Practices ERRORS USP san FDA median per Pa ate deere ee et eS pao Ne ee hee aoa santas a REPORNING PROGRAM, = Did the erorreachthe patent? ses. No Was the incrret medication, dose. o dosage form administered to or taken bythe patient? Qs Ono Cree the appropriate Error Outcome Category (elect one—see back for desis: AB oC DE F GH I Desctbe the dec rest ofthe error tothe patent (death, ype of harm, adational patent montorng) Indicate the possible eror causes) and contributing factor(s) fg, abbreviation, similar names, stration. et) Inccate the location ofthe error (., hospital outpatient or community pharmagy cn, nursing home. patents home etc) \What typeof staff or health care practitioner made the intial eror? Inccate if ther practioner] were als volved inthe error (ype of staf perpetuating erro hat ype of sta or healthcare practitioner discovered the eror or recogni the potent or ener? How was the err (or potential for eran dscoveredintercepted? \aalable provide patient age, gender, diagnosis Patient identifaton not equied Please complete the following for the product(s) involved, (If more space is needed for additional products, please attach a separate page) Product #1 Product #2 Brand Name Generic Name ee Manufacturer : = Labeler Dosage Form = StrengthConcentration = - ype and Siz of Contain ~-— Reports are most useful when relevant materials such as product label, copy of prescription/order, etc., can be reviewed. Can these materials be provided?) Yes Q1 No Please specify: _ Sugeest any recommendations to prevent recurrence of this err, describe poles or procedures you instituted or plan to institute to prevent future similar errors. i : Tephone Nariber Email ame aa Tice Telephone Naber Feity Nave, Aare, and Tip Your name and a copy ofthis report are routinely shared with the Insti ‘be sent to third parties such as the manufacturer/abeler, and to the Food ar ‘yur name on these copies. : 'm addition to releasing my name to ISMP, USP may release my Identity to these th Ch The manufacturer andor labeler as isted above (FDA (Other persons requesting 2 copy ofS reper, Signature iute for Safe Medication Practices (ISMPI. Copies of report wil snd Drug Administration (FDA). You have the option of including parties as follows (check boxes that apply): Anonymous to al third parties rh mre Wed aspen {or nek Ca burre 00025 EWOR (00255767 ‘Rocivte, MD 2085-1 ‘or FAX: 301-816-8532 od ited with permission of the Figure 23-1. The medication error form used by the United States Pharmacopeia. (Reprit United States Pharmacopeia.|496 Chapter 23 Vil A b. Proper communication of accurate patient medication information is critical for every ‘one involved in the patient's care. B. The 100,000 Lives Campaign from the Institute for Healthcare Improvement can be found at www. ihi.org/IHl/Programs/Campaigr’. 1. Use evidence-based therapeutic measures to prevent deaths from acute myocardial infarc. tion. 2. Prevent adverse drug events (ADEs) by implementing medication reconciliation and ensur- ing accurate and up-to-date medication records throughout the patient’s hospital stay. 3. Prevent central line infections by implementing appropriate procedures. 4, Prevent surgical site infections by appropriate care and antibiotic use. 5. Prevent ventilator-associated pneumonia by following appropriate proven steps. C. The IOM in July 2006 released its report “Preventing Medication Errors.”” Several recommenda- tions were made to improve patient safety including: enhancing role of patient in medication anagement, improving patient education, and increasing the use of technology, such as e-prescribing. This report can be accessed at www.iom.edu. D. Medication error reporting. The reporting of medication errors provides critical safety feed- back. Figure 23-1 shows the form used in the United States Pharmacopeia’s error reporting program. Errors can be submitted anonymously via the Internet, by telephone, or by mail