Medication safty
and Error
prevention
To Err is Human
Human Factors- Confront Two Myths
The perfection myth: The punishment myth:
Human Factors- Confront Two Myths
Medication Without Harm
First Challenge-2005 Clean Second Chellenge-2007 Third Chellenge-2017
care is safe care Safe Surgery Save Lives Medication without Harm
(Medication safety)
Definition
Medication Error:
Medication Safety:
A medical error is a preventable
Medication safety is defined as event that may cause or lead to
the freedom from accidental inappropriate medication use,
injury due to medical care or patient harm, or adverse health
medical error during the outcomes. These errors can occur
medication-use process at any stage of the healthcare
deserves the same prioritization, process, including diagnosis,
given the scope of medication use treatment, and preventive care,
in patient care and the frequency and can involve actions by
and severity of potential harm. healthcare providers, patients, or
systems.”
Medication Errors Statistics
United states
● Jhons Hopkins study (2016)
○ Estimated 250000 deaths annually due to medical error
○ Third leading cause of death
● Institute of medicine’s report “To Err Is Human”:
○ Estimated 44,000 to 98,000 deaths annually due to preventable adverse
events
Medication Errors Statistics
Global impact
● World Health organization
○ Medication error harm 1.3 million people annually
○ Cause one death every day in the US
○ Global cost estimated at $42 billion USD annually.
Swiss cheese model and medication error
Prescribing Dispensing Administrating
Prescribing Error
Wrong Dose: Incorrect Drug Ambiguous
Selection: Instructions:
A prescriber might
inadvertently The prescriber selects
a medication that is Prescriptions written
prescribe an
inappropriate for the with unclear
incorrect dose due patient’s condition, abbreviations or
to miscalculation or potentially due to a instructions.
confusion with drug lack of knowledge of
strength. the patient's history or
drug interactions.
Dispensing error
Look-Alike/Sound-Alike Drugs: Dispensing a drug that looks or sounds similar to the
prescribed one, leading to the wrong medication being given to the patient.
Labeling Errors: Mislabelling of the medication, which can result in the wrong dosage
or drug being administered. This includes inaccurate or missing information on the
label.
Dispensing Expired Medications: Dispensing medications that are past their
expiration date, which could reduce efficacy or increase the risk of harm to the patient.
Wrong Quantity: Dispensing an incorrect number of tablets, capsules, or vials, leading
to underdosing or overdosing over the treatment period.
Incorrect Storage Conditions: Storing medications inappropriately (e.g., not
refrigerated when required) and dispensing them in this compromised state.
Some look alike Drugs
Administration Errors
Wrong Time or Frequency: The medication is administered at the wrong time or
incorrect frequency, disrupting the intended therapeutic effect.
Incorrect Route of Administration: Administering the medication by the wrong
route (e.g., giving an oral medication intravenously).
Omission of Medication: The scheduled dose is not administered, which can be
especially dangerous for critical medications like anticoagulants or insulin.
A Pharmacists role in Preventing Medication Errors
1. Reviewing Prescriptions
2. Checking for Drug Interactions and Allergies
3. Counselling Patients
4. Double-Checking Dispensing
5. Promoting Medication Safety Systems
6. Monitoring High-Risk Medications
7. Reporting and Analyzing Medication Errors
Preventing Medication Errors at management level
● Development of a blame free & punishment free culture of medication error
reporting.
● Punitive action is not an effective way to prevent recurrence
● Medication error does not signify faulty personnel
● It signifies faulty systems that need to be made safer.
● Establishment of a voluntary reporting system which does not lead to blaming and
shaming of the individual care provider.
● Dedicated personnel (Clinical Pharmacologist)/ Team to collect and analize
Medication errors & device strategy for process improvement.
Guardians of Your Health: Compassion in Every Capsule."
