MEDICATION ERROR

What is Medication
Error?
 “Any preventable event that may
cause or lead to inappropriate
medication use or patient harm while
the medication is in control of the
health care professional, patient, or
consumer”
What is Medication
Error?
Any error in the
 Prescribing,
 Dispensing
 Administration of a drug
 Irrespective of whether such errors
lead to adverse consequences or not.
 A case for Medication errors
 Experts estimate that as many as 98,000
people die in any given year from medical
reasons that occur in hospitals. A significant
portion of those deaths is due to medication
errors.

 That's more than deaths occur from motor

vehicle accidents, breast cancer, or AIDS- three
causes that receive far more public attention.

 Indeed, more people die annually from

medication errors than from workplace injuries
Types of Medication Errors
1. Prescribing Errors
2. Dispensing errors
3. Administration Errors
a) Omission Error
b) Wrong time Error
c) Unauthorized Drug Error
d) Improper drug error
e) Wrong Dosage Form error
Continue…….

f) Wrong Dose preparation error

g) Wrong administration error
h) Deteriorated drug error

4. Miscellaneous errors
a) Monitoring error
b) Compliance error
 1. PRESCRIBING ERRORS

• Inaccurate history
taking
• Prescribing of a
contraindicated drug
• Errors in quantity &
indication
• Use of abbreviations
• Use of verbal orders
• Illegible handwriting
 Illegible Handwriting

Write complete and clear order with Drug name,

Dosage form, Strength, Dose, Route, frequency.
Wrong Drug & Wrong route

Drug drug interaction:

Warfarin prescribed to patient
already on Salicylate.

Duplicative therapy:
Atenolol ordered for patient already taking
metoprolol.

No indication:
Inj. Amikacin ordered for patient of UTI.

Wrong Route:
Betamethasone acetate suspension prescribed
to be given intraveneously.
 Contributing factors for
prescribing errors

• Work environment
• Workload
• Communication gap within the team
• Physical and mental well being
• Lack of knowledge
• Organizational factors (inadequate training)
• Low perceived importance of prescribing
• An absence of self awareness
 Approaches to reduce prescribing
errors

Electronic prescribing may help to reduce

the risk of prescribing errors resulting from
illegible handwriting

Computerized physician order entry

eliminate the need for transcription of
orders by nursing staff
Electronic Prescription
 Computerized physician order

Click icon to add picture

2. DISPENSING
ERRORS
 Unclear arrangement or
labeling of drugs
 Drugs that have a similar
name or appearance.
(LASA drugs)
 Wrong drug or wrong
patient due to increase
rush to pharmacy
 Dispensing of drug
having printing error
Drugs similar in appearance
Drugs similar in names (Major effects on
therapy)
Drugs similar in names (Minor effects on
therapy)
Various Dispensing Errors
Incorrect drug (Look alike sound alike
drugs)
Incorrect strength
Incorrect dosage form
Missing dose
Omission of item
Deteriorated medication
 How to prevent
dispensing errors ?
 Well designed drug storage
 Separating drugs having similar name and appearance.
 Use reminders such as labels and computer notes to prevent
mix-ups
 Use of ‘TALL MAN’ letter to emphasize the spelling of drug in
medication storage area. ( E.g. lamIVUDine & lamOTRIGine)
 Compare the contents of the medication container with the
information on the prescription
 Creating awareness of high risk drugs such as cytotoxic drugs.
 Maintaining the minimum workload at a safe and manageable
level.
 Introducing safe systematic procedure for dispensing of
medicines in the pharmacy.
 3. ADMINISTRATION
ERRORS
Discrepancy occurs between

the drug received by the patient

and the drug therapy intended
Errors of omission - the drug is
not administered
Incorrect administration technique
Incorrect dose, dosage form and time of
administration
administration of incorrect or expired
preparations.
Deliberate violation of guidelines
 a. Omission Error

It results form failure to administer

ordered dose.
Omitted dose is not an error when
 Patient cannot take anything from
mouth
 Providers are waiting for drug level/
laboratory data results
 Patient refuses
 b. Wrong Time Error
 Administration of a dose of
drug plus or minus “X” hours
from its scheduled
administration time. (“X” is
being set by hospital policy)

 Occasionally unavoidable:
when Medication is not
available at the due time
(out of stock) or Patient is
away from care area for test.
c. Unauthorized Drug Errors
Administration of drug to patient
without proper authorization by
prescriber.
Medication for particular patient
administered to another patient
Nursing staff administer drug without
prescriber order
Patients do share prescription
“Sometimes”
d. Improper Dose Error
 Dose being administer is
greater or less than actual
prescribed dose.
 May occur when
additional dose is
administered due to either
Delay in documentation or
Absence of documentation
 Inaccurate measurement
of oral liquid
e. Wrong Dosage Form Error
 Drugs administered as different form than ordered.
 Example: Hifenac instead of Hifenac SR

Administration of ophthalmic ointment

when eye drops prescribed
f. Wrong Dose Preparation
 Using saline (bacteriostatic) instead of sterile
water to reconstitute lyophilized powder for
injection.
 Incorrect dilution or reconstitution
 Mixing of drugs that are visually or chemically
incompatible
g. Wrong Administration
Techniques
SC injection
administered too
deep

IV drug is allowed

to infuse via gravity
instead of using IV
pump

Instilling eye drops

in wrong eye
h. Deteriorated Drug Error
Monitoring of expiry dates become essential
Refrigerated drugs being stored at room
temperature, hence, may decompose and
loose efficacy.
 Contributing Factors To
Drug Administration Errors

Failure to check the Environmental factors such a

patient’s identity prior to noise, interruptions, poor
administration lighting

Wrong calculation to
determine the correct dose
 Approaches To Reduce
Drug Administration Errors
Checking the patient’s identity
Ensuring that dosage calculations
Ensuring that the prescription, drug, and
patient are in the same place in order that
they may be checked against one another.
Ensuring the medication is given at the
correct time.
Minimizing interruptions during drug rounds
4. Miscellaneous errors
a. Monitoring Errors
 Inadequate drug therapy review
 Examples:
 Ordering serum drug level tests and not reviewing test
results
 Prescribing antihypertensive drugs and failing to
monitor blood pressure.
 b. Compliance
Errors

Failure to adhere to prescribed drug regimen

Metallic taste with metronidazole and
stopping the treatment

To save few doses and thereby save money,

patient does not complete entire regimen of
antibiotic.
Steps to prevent medication
errors
Targeted physician education on optimal
medication use
Inclusion of clinical pharmacists in decision
making activities
Computerized order entry by prescriber &
medication checking

Standardize processes & equipment

Avoid use of unknown abbreviations &

symbols
Double check patients having allergies
before prescribing
33
Preparing medicine in well lighted room

Check the expiry date of the drug before

administration

Medication Reconciliation

Standardised ordering and administration

Training, education, and organisational

interventions
34
Six step approach by WHO for
good prescribing
 Evaluate & clearly define patient’s problem

 Specify therapeutic objectives

 Select appropriate drug therapy: P-drug & STEPS approach

(Safety, Tolerability, Effectiveness, Price, Simplicity)

 Initiate therapy with appropriate details

 Give information, instructions & warnings

 Evaluate therapy regularly (e.g. Monitor treatment results)

35
Action To Be Taken When Error Occurs

 The client safety becomes the top priority

 The nurse assesses and examines the client’s condition

and notifies the physician of the incident as soon as
possible.
 Once the client is stable, the nurse should fill the
report of the incident. An incident report usually must
be filed within 24 hours of an incident.
 The nurse is also responsible to submit the report of
the incident to the appropriate person in the
institution like nursing supervisor or nursing manager.
 The Incident Report includes,
 client identifying information
the location
time of the incident

an accurate factual description of what

occurred and what was done with signature of the nurse
involved
• The incident report is not a permanent part of the medical
record and should not be referred to in the record.
• This is to legally protect the health care professional and
institution.
 The institution use incident report to track incident pattern
and to initiate quality, improvement programs as needed.
 It is good risk management to report all medication error
including mistakes that do not cause obvious or immediate
harm
 Be sure to read labels at least 3 times, before, during & after
administration of the drug.
 Prepare the medicine in a well lighted room.
 Check the expiry date of the drug before administration.
 Be aware about ambiguous orders or drug names and numerical
and Consult doctor if any doubt.
 Be alert to usually large dosage or excessive increase in dosage
ordered.
 When in doubt, check order with prescriber, pharmacist, literature .
 Do not use any non-standard abbreviation and symbols
 Read the leaflet carefully when giving new drug first time
 Do not accept incomplete orders and telephonic or verbal orders
 Double check with a client who has allergies
 Document all medication as soon as they are given
 Attend in-service program that focus on the drug you commonly
administer
 Stay updated with current state of knowledge