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Medication safety and Prevention of Medication errors.pptx
- 1. Medication safety and Preventionof Medication errors Presented By: Satinder Kaur Assistant Professor Critical care nursing
- 2. Highlights of thetopic • What is Medication safety? • What are the factors effects the medication safety? • What is medication errors? • Where the medication errors can happen? • What are the events followed to medication errors in different settings? • How medication errors can be prevented?
- 3. What is Medicationsafety “Medication without harm” • The medication safety is to ensure clinicians or health care workers safely prescribe, dispense and administer appropriate medicines. • • The safe medication procedure involves the implementation of safe medication procedure to bridge critical communication gaps in medication use process and to reduce negligence level.
- 4. Need of medicationsafety • Unsafe medication practices and errors are the leading cause of injury and avoidable harms in health care system. • As per WHO: - It is estimated that $ 42 billions USD medicines errors occur annually around the Globe. - Globally , The rate of medication error in hospital ranges from 0.3% - 9.1% in prescription and 1.6% - 2.1% at dispensing stage. • As per NIH (National Institutes of Health) : - In India , approximately 5.2million medication errors takes place at various stages in health care system . - It is estimated that major reason behind this is irrational use of medication.
- 6. What are Medicationerrors • Medication errors are the most common errors in hospital settings • The events of errors in medication prescription, uses, dispensing and observation in effects can lead to various life threatening situations. • The errors can be different as per environment from the patient administer self medication to patient receiving medication in clinics and hospitals
- 7. What is medicationerror 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. OR Any error in the process of ordering, transcribing, dispensing, administering and monitoring a medication. A medication error may or may not result in an actual or potential adverse drug event.
- 8. How medical errorclassified • Any step in the medication process • Omissions • Commission • Documentation • Near misses • If there is no consequences
- 9. • Commissions: Mistakein diagnosis and error in treatment prescription • Omission: Missed diagnosis and appropriate treatment as per diagnosis not given • Near Miss: A wrong treatment but did not cause harm How medical error classified
- 10. How medication errorsoccur The medication error can occur at any stage at the following: Prescription errors Dispensing errors Drug administration errors Compliance errors General errors
- 11. General Errors As perthe AMCP (Academy of managed care pharmacy) : • Inadequate and inappropriate professional practice: • Poor health care products: • Wrong procedures : • Poor lightening environment and poorly designed medical devices • Inadequate staffing pattern • Lack of independent ineffective double check system for high alert drugs Irrational use of medication Product quality, labeling, packaging and nomenclature Inadequate prescription, dispensing and administration of drug
- 13. Prescription Errors These errorsoccurs at the physician side: • Inappropriate diagnosis and lack of knowledge regarding disease. • Illegible hand written prescription slip • Insufficient or minor information about co – prescribed drugs. • Inadequate knowledge dissemination regarding past taken medication dosage and response
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- 15. • The selectionof complex regimen • Selection of incorrect dosage and drug • Oral prescription with similar names of drugs • Unclear Handwritten prescription slip with similar trade name of drugs. • Inadequate communication of allergic sensitivities and laboratory values. • Prescription with naked decimals points and terminal zeroes (e.g. 0.5 mg written as .5 mg) Prescription Errors
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- 17. • Verbal Orders •Communication issues: - Accents, dialects - Background noises and interruptions - Unfamiliar drug names and terms “More steps = More risk of error” Prescription Errors
- 18. Verbal Order errors: •Wrong Drug • Clonidine misheard as Klonopin • Amiodarone misheard as amrinone • Wrong Dose • Toradol 15 mg misheard as 50 mg • Wrong Labs • Blood glucose misheard as 257 instead of 157 patient received 6 units of insulin instead of 2 Prescription Errors
- 19. Dispensing Errors The errorsrelated to pharmacy and pharmacist: • Dispense the wrong drug and dosage strength • Incorrect entry into the computer record • Fail to identify drug interactions, relationships and contraindications • An ambiguous language on the label • Outdated or expiry dated drug dispensing • Negligence in clearing the doubts related to drug name, indications, dosage and special instructions written on prescription slip.
- 20. Dispensing Errors • Overoccupied pharmacist can exchange the drugs to different patients during dispensing • Lack of double check before dispensing drugs • Drug calculation errors • Same color container confusion • Poor environment (poor lightening , noise , interruptions etc.)
- 21. These errors occurin the hospitals and wards by nurses: • Adverse drug reaction: When nurses fails to ask about allergies before administration of drug. • Administration errors: Failed to administer prescribed dosage to patient before next scheduled time of administration. • Wrong time error: Administration of medication outside a predefined time interval from its scheduled administration time. Drug Administration Errors
- 22. Poor communication Carelessness Multiple interruptions Stress Lackof knowledge working conditions Drug Administration Errors
- 23. • Unauthorized drugerror: Administration of medication to the patient not authorized by the legitimate prescriber or physician. • Improper dosage error: Administration of either higher or lower dosages of drugs during error in calculation than prescribed by physician. • Wrong route of administration: Drug administered through wrong route e.g. injection given I/V instead of Intradermal. • Wrong drug preparation error: ; Drug product incorrectly formulated or manipulated before administration. Drug Administration Errors
- 24. • Drug administrationtechnique error: Inappropriate procedure or wrong technique use during drug administration. • Deteriorated drug error: Administration of expired drug or drug which has deteriorated composition and compromised with quality of drug. • Monitoring error: Failure to assess the effectiveness of drug and inadequate assessment of patient to prescribed regimen after administration for any adverse effects. Drug Administration Errors
- 25. These errors occurat the patient and care taker side during receiving regimens or discharge health teaching: • Don’t take an active role in understanding what is being communicated to them. • Do not communicate the effects of drug they felt after taking it. • Compliance Errors
- 26. • Patients didnot ask about important questions related to drug consumption like: -What time is best to take drug? - How drug has to be taken with meal, before meal or after meal? -What interactions can happen with other drugs patient is consuming? - What common side effects can occur and when he has to report to physician? - How he can mange common side effects at home? - What happened if he missed a dosage and what he has to do? Compliance Errors
- 27. • Patient donot check label of drug before collecting from pharmacy for storage and any other important instructions regarding drug. • People do not check expiry date of drug. • At home do not administer drug to patient at timely manner. • Inappropriate patient behavior regarding adherence to a prescribed medication regimen. Compliance Errors
- 28. MEDICATION ERROR ANALYSIS MONITORING TRAINING Medication Error MANPOWERDOCUMENTATION Shortage of doctors Infrequent audits No over sight by Nursing TL Lack of knowledge & Staffs untrained on Medication administration Doctors are not trained on medication reconciliation Staffs not sensitised about medication error Documented before administration New Nursing staff Joined Wrong transcription No Documentation Wrong documentation No over sight of Doctors notes Cross checking was not happen COMMUNICATION Hand Over communication was not proper Communication Gap between doctors and Nursing ; Nursing , Pharmacist and Doctors PRESCRIPTION Escalation not happen Incomplete Prescription Illegible handwriting Special instruction was not written Shortage of Pharmacist Pharmacist are not trained
- 29. Prevention: Medication errors Thefollowing instructions to patient can help in preventing medication errors: • Know the names and indications of your medications • Read the information sheet regarding drug before taking it provided by pharmacist Check the label for expiry date, special instructions and technique of consuming drug. • Do not share medication with other family members. • Learn about proper drug storage. • Learn about potential drug interactions, side effects and warnings.
- 30. At the physicianside: • The clinicians should ensure about clear and understandable prescription and administration techniques of regimens. • Clear and understand able communication regarding drugs and treatment with the patient in patient’s language. • Properly explain regimens to nursing staff in ward and do monitoring. • To read and acquire sufficient knowledge regarding drug before prescription and adhere with institutional policies regarding drug prescription Prevention: Medication errors
- 31. The nurses canprevent medication errors with following strategies: • Ensure five rights of medication: Nurses must ensure that institutional policies related to medication transcription are followed. It isn’t adequate to transcribe the medication as prescribed, but to ensure the correct medication is prescribed for the correct patient, in the correct dosage, via the correct route, and timed correctly (also known as the five rights). “Right patient, Right drug, Right time, Right dosage, Right route” Prevention: Medication errors
- 32. • Follow propermedication reconciliation procedure: All the Institutions/Hospitals must have mechanisms in place for medication reconciliation during transfer of a patient out of hospital or within hospital from one unit to another unit. Nurses must Review and verify each medication for the correct prescription, record and five rights of drug administration at the time of transfer and receiving of the patient. Nurses must compare this to the medication administration record (MAR). Prevention: Medication errors
- 33. • Double check/triple check procedures: Nurses must ensure to review the prescription orders during every shift and to communicate new orders to incoming shift staff. Nurses are responsible to maintain medication administartion record (MAR) updated • Have the prescriber (or another medical staff) read it back: This is a process whereby a medical staff reads back an order to the prescribing physician to ensure the ordered medication is transcribed correctly. Prevention: Medication errors
- 34. • Consider usinga name alert: Some institutions use name alerts to prevent similar sounding patient names from potential medication mix up. Names such as Johnson and Johnston can lead to easy confusion on the part of nursing staff. • Place a zero in front of the decimal point: A dosage of 0.25mg can easily be construed as 25mg without the zero in front of the decimal point, and this can result in an adverse outcome for a patient. • Records and Documentation: This includes proper medication labeling, legible documentation, or proper recording of administered medication Prevention: Medication errors
- 35. • Medication storage:Nurses must ensure to read the label of drug for appropriate storage technique of drugs. Label the multidose vial in use for information regarding date of opening and expiry. • Medication administration policies: Nurses must be educated about institutional medication administration, documentation and error reporting policies by the education /administration department of the institution. • Drug guide: Nurses must carry latest edition of drug guide with them to have sufficient knowledge regarding drug before administering to patient and to recheck physician’s orders. Prevention: Medication errors
- 36. Computer Physician entry(COPE): • Reduce errors / adverse drug events of hand writing • Produce legible and complete orders • Flag laboratory results that affect prescribing • Inform ordering MDs of drug interactions, allergies, and duplication • Make easy to maintain record as well as to understand for other medical staff team. • Alert regarding patient allergies. Prevention: Medication errors
- 37. Digital Assistants (PDAs):It involves Bar Code point of care (BPOC) by using Bar Code Bedside device. • Wireless Laptop computer with a touch screen and bar code scanner Prevention: Medication errors
- 38. • Nurse barcodescans name tag • Nurse barcode scans patient identification bracelet • Patient MAR appears on bedside laptop • Scheduled and prn meds are scanned • Warnings/alerts are issued when indicated Prevention: Medication errors
- 39. • Institute mustensure to formulate easy and accessible guidelines for error reporting. • Institute must educate and encourage health care team to report errors fearlessly and early. • Pharmacists are in ideal position to report medication errors • Maintain confidentiality of individual reporting the error. Medication errors Reporting
- 40. Pharmacist: “The backbone”of Reporting Errors . 40
- 41. Key Points toremember • It is human to error, but it is also human to react and create solutions • Errors happen every day, but don’t always cause harm • Prevention is multi-factorial • Response to an error is paramount • Reporting is the foundation for improvement