NABH_Medication_Errors_Presentation_Touch_Hospital.pptx

Medication Errors & NABH
Standards
Presented by: Anil Devaraj
Operations Manager, Touch Hospital,
Mancherial

Introduction
What are Medication Errors?
- Any preventable event that may cause or lead to
inappropriate medication use or patient harm.
Types of Medication Errors:
- Prescribing errors
- Dispensing errors
- Administration errors
- Monitoring errors

Prescription errors occur during the process of prescribing medications. These errors can result in incorrect drug therapy, leading
to potential harm or therapeutic failure for patients.
Prescription Errors
Types of Prescription Errors
1.Incorrect Drug Selection
•Prescribing a medication that is inappropriate for the patient's condition.
•Example: Prescribing an antibiotic for a viral infection.
2.Wrong Dosage
•Prescribing a dose that is too high or too low for the patient’s age, weight, or condition.
•Example: Prescribing 500 mg instead of 50 mg for a pediatric patient.
3.Incomplete or Inaccurate Prescription
•Missing essential details such as dosage form, route of administration, or frequency.
•Example: Prescribing a medication without specifying "oral" or "intravenous."
4.Use of Abbreviations
•Misinterpreted abbreviations leading to incorrect dosing or medication errors.
•Example: "U" (units) being mistaken for "0," resulting in a tenfold overdose.
5.Illegible Handwriting
•Poor handwriting that leads to misinterpretation of the prescribed drug or dose.
•Example: A handwritten prescription for "Lasix" (furosemide) being misread as "Lamisil" (terbinafine).
6.Failure to Consider Patient Factors
•Not accounting for allergies, renal or hepatic impairment, or potential drug interactions.
•Example: Prescribing NSAIDs to a patient with a history of peptic ulcers.
7.Incorrect Duration of Therapy
•Prescribing a medication for an inappropriate duration.
•Example: Prescribing antibiotics for 3 days instead of the required 7 days.
8.Polypharmacy and Drug Interactions
•Prescribing multiple medications without considering interactions or cumulative effects.

Dispensing Errors
Dispensing errors occur during the preparation, packaging,
labeling, or distribution of medications in a pharmacy. These
errors can lead to incorrect medications being administered,
resulting in harm to patients.

1.Incorrect Medication
•Dispensing the wrong drug.
•Example: Prescribing Paracetamol, but dispensing Ibuprofen.
2.Incorrect Dosage
•Dispensing the wrong strength or quantity.
•Example: Prescribing 50 mg, but dispensing 500 mg.
3.Labeling Errors
•Incorrect or missing information on the medication label.
•Example: Missing dosage instructions or incorrect patient name.
4.Formulation Errors
•Dispensing the wrong dosage form (e.g., tablet instead of syrup).
•Example: Prescribing oral suspension but providing capsules.
5.Failure to Detect Drug Interactions
•Dispensing a drug that has a harmful interaction with the patient’s current
medications.
6.Incorrect Patient
•Dispensing the medication to the wrong patient.
•Example: Medication labeled for Patient A is given to Patient B.
Types of Dispensing Errors

•Look-Alike Sound-Alike (LASA) Drugs
Similar packaging or names, leading to confusion.
Example: Metformin and Metronidazole.
•Workload and Fatigue
Overworked pharmacists may overlook critical details.
•Communication Failures
Miscommunication between the prescribing doctor and the pharmacist.
•Inadequate Training
Insufficient knowledge about the drug or its interactions.
Impact of Dispensing Errors
•Patient Harm: Adverse drug reactions, toxicity, or therapeutic failure.
•Increased Healthcare Costs: Hospital readmissions and additional treatments.
•Legal Implications: Lawsuits and loss of reputation.
•Loss of Patient Trust: Reduced confidence in healthcare providers.
Causes of Dispensing Errors

Administration errors occur during the process of giving the prescribed medication to the patient. These errors
are critical because they directly affect patient safety and can lead to serious adverse outcomes
Administration Errors
Types of Administration Errors
1.Wrong Medication
•Administering a medication that was not prescribed.
•Example: Giving Atorvastatin instead of Amlodipine.
2.Wrong Dose
•Administering a dose higher or lower than prescribed.
•Example: Prescribing 500 mg but administering 50 mg.
3.Wrong Route
•Administering the drug via the incorrect route (e.g., oral instead of intravenous).
•Example: Giving a medication intramuscularly instead of intravenously.
4.Wrong Time
•Administering the medication at the wrong time or missing a dose entirely.
•Example: Prescribed every 8 hours, but given every 12 hours.
5.Omission Errors
•Failing to administer a prescribed medication altogether.
•Example: Skipping a dose of antibiotics during a critical infection.
6.Unauthorized Drug Administration
•Administering a drug that was discontinued or never prescribed for the patient.
7.Incorrect Rate of Administration
•Administering an IV infusion too quickly or too slowly.
•Example: Rapid infusion of potassium chloride, leading to cardiac complications.
8.Failure to Document
•Not recording the administration of the drug, leading to repeated doses or missed doses.

1.Human Factors
•Fatigue, distractions, or multitasking by nurses or caregivers.
2.Communication Failures
•Misunderstandings or incomplete handoffs during shift changes.
3.Similar Packaging
•Confusing two different medications due to similar packaging.
4.Lack of Training
•Inadequate knowledge of drug administration protocols.
5.Poor Patient Identification
•Administering medication to the wrong patient due to incorrect identification.
Impact of Administration Errors
•Adverse Drug Reactions
Allergic reactions, toxicity, or lack of therapeutic effect.
•Patient Harm
Increased morbidity, prolonged hospital stay, or even death.
•Legal and Ethical Implications
Lawsuits, loss of licensure, and damage to hospital reputation.
Causes of Administration Errors

Monitoring errors occur when healthcare providers fail to properly observe or assess a patient's response to a
medication. These errors can lead to unrecognized adverse drug reactions, therapeutic failures, or toxic effects.
Monitoring Errors in Medication Management
Types of Monitoring Errors
1.Failure to Monitor Therapeutic Effects
•Not assessing whether the medication is achieving the intended effect.
•Example: Failing to monitor blood pressure after administering antihypertensive drugs.
2.Failure to Detect Adverse Drug Reactions (ADRs)
•Missing early signs of side effects or allergic reactions.
•Example: Not recognizing skin rash as a sign of an allergic reaction to antibiotics.
3.Failure to Monitor Drug Levels
•Neglecting to measure drug concentrations for medications with narrow therapeutic windows.
•Example: Not monitoring serum levels of warfarin or digoxin, leading to toxicity.
4.Inadequate Monitoring of Vital Signs
•Failing to observe changes in vital signs after administering critical medications.
•Example: Not monitoring respiratory rate after administering opioids, leading to respiratory depression.
5.Failure to Monitor for Drug Interactions
•Not considering how newly prescribed medications may interact with existing treatments.
•Example: Prescribing a drug that increases the risk of bleeding when the patient is already on anticoagulants.
6.Delayed Recognition of Treatment Failure
•Not identifying that the medication is ineffective and failing to adjust the treatment plan.
•Example: Continuing an antibiotic despite persistent infection.

Causes of Medication Errors
- Lack of proper communication
- Incorrect prescribing or transcription
- Inadequate patient education
- Poor labeling or packaging
- Similar drug names (Look-Alike Sound-Alike
drugs)
- Workload and fatigue of healthcare staff

Common Causes of Medication Errors
Icons or illustrations showing:
Communication breakdown between healthcare staff.
Similar drug names (Look-Alike Sound-Alike drugs).
Poor or unclear labeling.
Fatigued healthcare workers.
Overcrowded or busy hospital environments.

Impact of Medication Errors
- Patient Harm: Adverse drug reactions,
complications, or death
- Psychological Impact: Loss of trust in
healthcare providers
- Financial Consequences: Increased healthcare
costs, legal liabilities
- Reputation: Negative impact on hospital
accreditation and quality ratings

NABH Standards on Medication Safety
• Emphasis on Patient Safety (Chapter 4 -
Medication Management and Use)
• Key Objectives:
• - Ensure safe storage, prescription, and
administration of medications
• - Regular medication audits and error reporting
• - Implementation of corrective and preventive
actions

Strategies to Prevent Medication Errors
- Standardized Protocols: Use of checklists for
prescribing, dispensing, and administration
- Training & Education: Regular staff training on
medication safety
- Use of Technology: Electronic prescribing systems
(CPOE), Barcode medication administration
(BCMA)
- Patient Involvement: Educate patients on their
medications, including dosage and side effects

Error Reporting & Analysis
• - Importance of Reporting: Non-punitive
culture for reporting errors
• - Error Analysis: Root Cause Analysis (RCA)
for understanding the cause
• - Implementing corrective actions based on
findings

Medication Reconciliation
• Process of verifying the patient's medication
list at transitions of care:
• - Admission
• - Transfer between departments
• - Discharge

Key Performance Indicators (KPIs)
- Percentage of medication errors reported
- Time taken to resolve reported errors
- Patient satisfaction scores regarding
medication information
- Compliance with NABH standards

Role of Leadership in Medication Safety
- Commitment to a culture of safety
- Regular review and audits of medication
management
- Allocating resources for training and
technology

Conclusion
- Medication errors are preventable with proper
systems and processes in place.
- Compliance with NABH standards ensures
patient safety and enhances the hospital’s
credibility.
- Continuous improvement and teamwork are
essential to achieving zero medication errors.

Q&A
• Questions? Thank you for your attention!
• Contact: Anil Devaraj, Operations Manager,
Touch Hospital

NABH_Medication_Errors_Presentation_Touch_Hospital.pptx

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