Medication Safety
Mita Restinia, M.Farm, Apt
Medication Error Deaths Increasing
Deaths from
Medication Errors
1983 1998
Phillips DP. Annu Rev Public Health. 2002;23:135-50.
Learning objectives
To provide an overview of medication
safety
To encourage you to continue to
learn and practise ways to improve the
safety of medication use
Medication Error (ME)
A medication error is ‘a failure in the treatment process
that leads to, or has the potential to lead to, harm to the
patient’ (Aronson JK, 2009)
The ‘treatment process’ includes treatment for symptoms or their
causes or investigation or prevention of disease or physiological
changes. it also includes the manufacturing or compounding,
prescribing, transcribing (when relevant), dispensing,and
administration of a drug,and the subsequent monitoring of its effects.
Introduction
Medication safety defined as freedom from
preventable harm with medication use, for
example medication error
https://www.11alive.com/article/news/loc
al/investigations/womans-skin-melts-off-
after-medication-error/437871972
any preventable event that has the potential to inappropriate
medication use or patient harm during prescribing,
transcribing, dispensing, administering, adherence, or
monitoring a drug
Medication errors that are stopped before harm can occur are
sometimes called “near misses” or more formally, a potential
adverse drug event
The Relationship Among ME,
ADEs, & ADRs
Medication
Errors ADEs
ADRs
Nebecker et al. Ann Intern Med 2004;140: 795-801, J Gen Med 10:199-205,1995.
Definitions
Adverse event: an incident that results in harm to a patient
Side-effect: a known effect, other than that primarily intended,
relating to the pharmacological properties of a medication
e.g. opiate analgesia often causes nausea
Adverse reaction: unexpected harm arising from a justified action
where the correct process was followed for the context in which
the event occurred
e.g. Allergies
WHO: World alliance for patient safety taxonomy
Risk of medication error
Selection & Prescribing Preparing & Administering Monitoring
Procuring Assess patient; Dispensing Review dispensed Assess patient
Establish determine need for Purchase & store drug order; assess response to drug;
formulary drug therapy; select drug; review & patient & report reactions
& order drug confirm order; administer & errors
distribute to patient
location
Clinician & Physician/ All practitioners,
Pharmacist Nurse/other health
administrators prescriber plus patient &/or
professionals
family
Joint Commission. 1998
Major Areas for Medication Error
Prescribing
38% 39% Transcribing
Dispensing
12% 11%
Administering
Medication Errors Reporting Program US
Prescribing Errors
It is an incorrect drug selection for a patient. Such errors can include the
dose, strength, route, quantity, indication, or prescribing
contraindicated drug
Lipitor 10mg PO QD
Filled Rx: Zyrtec 10mg
Williams DJ. 2007,
Lesar et al. JAMA. 1997
Prescribing Errors….. Examples
Name That Drug…
6 units of regular insulin now
Prescribing
Errors…..Examples
Sometimes the technology itself is the problem…
Monopril 40mg
Filled Rx: Monopril 10mg
How can prescribing go wrong?
inadequate knowledge about drug indications and contraindications
not considering individual patient factors such as allergies,
pregnancy, co-morbidities, other medications
wrong patient, wrong dose, wrong time, wrong drug, wrong route
inadequate communication (written, verbal)
documentation - illegible, incomplete, ambiguous
mathematical error when calculating dosage
incorrect data entry when using computerized prescribing e.g.
duplication, omission, wrong number
Dispensing Errors
It is an error that occurs at any stage during the dispensing process
from the receipt of a prescription in the pharmacy through to the
supply of a dispensed product to the patient
Studies have estimated that dispensing errors occur at a rate of 1-
24%
These errors include the selection of the wrong strength/product.
This occurs primarily when ≥ 2 drugs have a similar appearance or
similar name (LASA=look-a-like/sound-a-like errors)
Dispensing
Errors…..Examples
Look-a-like
Sound-a-like medications
Celebrex (an anti-inflammatory) : celecoxib
Cerebryx (an anticonvulsant) : fosphenytoin
Celexa (an antidepressant) : citalopram
Administration Errors
Defined as a discrepancy between the drug therapy received by the
patient & the drug therapy intended by the prescriber
Drug administration is associated with one of the highest risk areas in
nursing practice
How can drug administration
go wrong?
wrong patient
wrong route
wrong time
wrong dose
wrong drug
omission, failure to administer
inadequate documentation
Monitoring involves …
observing the patient to determine if the medication is working,
being used appropriately and not harming the patient
Documentation
How can monitoring go wrong?
• lack of monitoring for side-effects ex: short breath cause of beta
blocker
• Drug not ceased if not working or course complete, ex: antibiotic
• drug ceased before course completed ex: anti tuberculosis drug,
antibiotic
• drug levels not measured, or not followed up on, ex: drug dose
inappropriate
• communication failures
Which patients are most at risk of
medication error?
• patients on multiple medications
• patients with another condition, e.g. renal impairment,
pregnancy
• patients who cannot communicate well
• patients who have more than one doctor
• patients who do not take an active role in their own
medication use
• children and babies (dose calculations required)
HOW TO PREVENT
MEDICATION ERROR
How to prevent medication error
1. use generic names
2. tailor prescribing for each patient
3. learn and practise thorough medication history taking
4. know the high-risk medications and take precautions
5. know the medications you prescribe well
6. use memory aids
7. communicate clearly
8. develop checking habits
9. encourage patients to be actively involved
10. report and learn from errors
1. Tailor your prescribing for each
individual patient
Consider:
allergies
co-morbidities (especially liver and renal impairment)
other medication
pregnancy and breastfeeding
size of patient
Learn and practise thorough
medication history taking
include name, dose, route, frequency, duration of every drug
recently ceased medications
ask about over-the-counter medications, dietary supplements and
alternative medicines
consider drug interactions, medications that can be ceased and
medications that may be causing side-effects
always include allergy history
Know which medications are high risk
and take precautions
narrow therapeutic window
multiple interactions with other medications
potent medications
complex dosage and monitoring schedules
examples:
oral anticoagulants
Insulin
chemotherapeutic agents
neuromuscular blocking agents
aminoglycoside antibiotics : ottotixicity
intravenous potassium
emergency medications (potent and used in high pressure situations)
Remember the 5 Rs when
prescribing and administering
Can you remember what they are?
right drug
right dose
right route
right time
right patient
Develop checking habits
when prescribing a medication
when administering medication:
check for allergies
check the 5 Rs
remember computerized systems still require checking
always check and it will become a habit!
Develop checking habits
some useful maxims …
unlabelled medications belong in the bin
never administer a medication unless you are 100% sure you
know what it is
practise makes permanent, perfect practice makes perfect
so start your checking habits now
Encourage patients to be actively
involved in the process
when prescribing a new medication provide patients with the
following information:
name, purpose and action of the medication
dose, route and administration schedule
special instructions, directions and precautions
common side-effects and interactions
how the medication will be monitored
encourage patients to keep a written record of their medications and
allergies
encourage patients to present this information whenever they
consult a doctor
Calculation errors
Can you answer the following question?
A 12 kg, 2-year-old boy requires 15
mg/kg of a medication that comes as a
syrup with a concentration of 120
mg/5mls. How many mls do you
prescribe?
Case Study 1
• a patient is commenced on oral anticoagulants in hospital for
treatment of a deep venous thrombosis following an ankle
fracture
• the intended treatment course is 3-6 months though neither
the patient nor community doctor are aware of the planned
duration of treatment
• patient continues medication for several years, being
unnecessarily exposed to the increased risk of bleeding
associated with this medication
• the patient is prescribed a course of antibiotics for a dental infection
• 9 days later the patient becomes unwell with back pain and
hypotension, a result of a spontaneous retroperitoneal haemorrhage,
requiring hospitalization and a blood transfusion
• international normalized ratio (INR) reading is grossly elevated,
anticoagulant effect has been potentiated by the antibiotics
Problem: Prescribing, drug interaction
Can you identify the contributing
factors for this medication error?
• lack of communication and hence continuity of care between the
hospital and the community
• patient not informed of the plan to cease medication
• the interaction between antibiotic and anticoagulant was not
anticipated by the doctor who prescribed the antibiotic even though
this is a known phenomenon
• lack of monitoring; blood tests would have detected the exaggerated
anticoagulation effect in time to correct the problem
How could this error have been prevented?
• effective communication
– e.g. discharge letter from hospital to community doctor
– e.g. patient information
• memory aids and alerting systems to help doctors notice potential
adverse drug interactions
• being aware of common pitfalls in medications you prescribe
• monitoring medication effects when indicated
How could the patient help prevent
this error?
by asking more questions:
“How long will I need this new medication for?”
“Will this antibiotic interact with my other medication?”
How can the doctor encourage the patient to ask more
questions?
Case Study 2
• a 74-year-old man sees a community doctor for treatment of
new onset stable angina
• the doctor has not met this patient before and takes a full
past history and medication history
• he discovers the patient has been healthy and only takes
medication for headaches
• the patient cannot recall the name of the headache
medication
• the doctor assumes it is an analgesic that the patient takes
whenever he develops a headache
• but the medication is actually a beta-blocker that he takes
every day for migraine; this medication was prescribed by a
different doctor
• the doctor commences the patient on aspirin and another
beta-blocker for the angina
• after commencing the new medication, the patient develops
bradycardia and postural hypotension
• unfortunately the patient has a fall three days later due to
dizziness on standing; he fractures his hip in the fall
Problems
Prescribing : fail to decide the right drug to the right patients
What factors contributed to this
medication error?
two drugs of the same class prescribed unknowingly with
potentiation of side-effects
patient not well informed about his medications
patient did not bring medication list with him when consulting
the doctor
doctor did not do a thorough enough medication history
two doctors prescribing for one patient
patient may not have been warned of potential side-effects
and of what to do if side-effects occur
How could this situation have
been prevented?
patient education regarding:
regular medication
potential side-effects
the importance of being actively involved in their own care - e.g. having a
medication list
more thorough medication history
Case Study 3
• a 38-year-old woman comes to the hospital with 20 minutes of itchy
red rash and facial swelling; she has a history of serious allergic
reactions
• a nurse draws up 10 mls of 1:10,000 adrenaline (epinephrine) into a
10 ml syringe and leaves it at the bedside ready to use (1 mg in total)
just in case the doctor requests it
• meanwhile the doctor inserts an intravenous cannula
• the doctor sees the 10 ml syringe of clear fluid that the nurse has
drawn up and assumes it is normal saline
• there is no communication between the doctor and the nurse at this time
• the doctor gives all 10 mls of adrenaline (epinephrine) through the
intravenous cannula thinking he is using saline to flush the line.
• the patient suddenly feels terrible, anxious, becomes tachycardic and then
becomes unconscious with no pulse
• she is discovered to be in ventricular tachycardia, is resuscitated and
fortunately makes a good recovery
• recommended dose of adrenaline (epinephrine) in anaphylaxis is 0.3 - 0.5 mg
IM, this patient received 1mg IV
Problems: Dispensing & Administration
Can you identify the contributing
factors to this error?
assumptions
lack of communication
inadequate labeling of syringe
giving a substance without checking and double-checking what it is
lack of care with a potent medication
How could this error have been prevented?
never give a medication unless you are sure you know what it is; be
suspicious of unlabelled syringes
never use an unlabelled syringe unless you have drawn the
medication up yourself
label all syringes
communication - nurse and doctor to keep each other informed of
what they are doing
e.g. nurse: “I’m drawing up some adrenaline”
develop checking habits before administering every medication …
go through the 5 Rs
e.g doctor: “ What is in this syringe?”
