CLINICAL PHARMACY

NISHAT SHAIK
PHARM.D 4/6(P.B)
Regd No. 618109502028
Contents:

➢ Definition
➢ Sources of Medication Errors
➢ Factors Contributing to Medication Errors
➢ Types of Medication Errors
➢ Categorisation of Medication Errors
➢ Steps to be taken in preventing medication error
➢ Steps to minimize Medication Error
➢ Role of Pharmacist in Improving Medication Safety
➢ Conclusion
➢ Reference 2
 ➢ DEFINITION:
● Medication errors, broadly defined as any error in the prescribing,
dispensing, or administration of a drug, irrespective of whether such errors
lead to adverse consequences or not.

● 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.

● In simple terms: It can be defined as any deviation from the Prescriber’s order.
● Such events may be related to professional practice, health care products,
procedures, and systems, including prescribing; order communication; product
labeling, packaging, and nomenclature; compounding; dispensing; distribution;
administration; monitoring; and use."

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❖ SOURCES OF MEDICATION ERROR:
● Inaccurate recording.
● Unclear labeling of drugs
● Misidentification of Patient
● Incomplete delivery of drugs
● Use of inadequate knowledge or inaccurate knowledge base.
● Time and performance pressure

➢ FACTORS CONTRIBUTING TO MEDICATION

ERROR:
• HUMAN-RELATED
• SYSTEM-RELATED
• MEDICATION-RELATED
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 HUMAN-RELATED
Providers Patients

➔ Overworked ➔ In a hurry
➔ Under-trained ➔ Health literacy level
➔ Distracted ➔ Do not understand the
➔ Illness medication/use
➔ Stressed ➔ Trust providers to not make
mistakes

SYSTEM-RELATED MEDICATION-RELATED
• Lack of communication
• Poor workflow
• Look-alike/sound-alike medications
• Disorganized workspace
• Multiple dosage forms and strengths
• Inadequate tools to complete work
• Lack of supervision
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➢ SOME OTHER FACTORS WHICH CONTRIBUTE TO
MEDICATION ERRORS:

• 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
• Lack of knowledge about medication
• Dosage calculation
• Insufficient training
• Insufficient hospital training

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➢ TYPES OF MEDICATION ERRORS
➢ Medication errors include:

1. Prescribing Error
2. Dispensing Error
3. Administration Error
4. Documentation(Transcription) Error
5. Omission Error
6. Wrong Time Error
7. Unauthorized Drug Error
8. Improper Dose Error (Under-Dose and Over-Dose)
9. Wrong Dosage Form Error
10. Compliance Error

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➢ PRESCRIBING ERROR:
● Incorrect drug selection (based on indications, contraindications,
known allergies, existing drug therapy and other factors), dose,
dosage form, quantity, route of administration, concentration, rate
of administration or

It includes:

▪ Incorrect Prescription
▪ Illegible Handwriting
▪ Drug allergy not identified
▪ Irrational combinations https://www.slideshare.net/maryline1979/medication-error-25474916

▪ Out of list abbreviation

▪ Misplacement of Decimal Point

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Reference:

https://www.slideshare.net/maryline1979/medication-error-25474916

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❑ CONTRIBUTING FACTORS INCLUDE:
• Illegible handwriting.
• Inaccurate medication history taking.
• Confusion with the drug name. .
• Use of abbreviations (e.g. AZT has led to confusion between zidovudine and azathioprine).
• Use of verbal orders.
• Always use leading zeros for decimal points. The order should have read: Digoxin 0.5 mg

❑ Risk factors for prescribing errors:

• Work environment
• Workload Communication within the team.
• Physical and mental well being
• An absence of self awareness of errors

❑ Approaches for reducing prescribing errors:

• Electronic prescribing may help to reduce the risk of prescribing errors resulting from illegible
handwriting

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➢ DISPENSING ERROR:

● A dispensing error is a discrepancy between a prescription and

the medicine that the pharmacy delivers to the patient or
distributes to the ward on the basis of this prescription, including
the dispensing of a medicine with inferior pharmaceutical or
informational quality

❖ COMMON CAUSES

➢ Work environment
➢ Workload
➢ Distractions
➢ Use of outdated or incorrect references
➢ LASA drugs (Look Alike Sound Alike)
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DISPENSING ERRORS…..EXAMPLES

LOOK ALIKE MEDICINES:

Reference:

https://slideplayer.com/slide/12640416 /

SOUND- ALIKE MEDICINES:

Reference:

https://www.slideshare.net/cetdmgh/m
edication-error-16770312

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 MOST OF THE PREVALENT DISPENSING ERRORS
• Dispensing incorrect medication, dosage strength, or dosage form
• Dosage miscalculations
• Failure to identify drug interactions or contraindications

❖ Approaches for reducing dispensing errors include:

● Ensuring a safe dispensing procedure

● Separating drugs with a similar name or appearance
● Keeping interruptions in the medicine administration procedure to a
minimum and maintaining the workload of the nurse at a safe and
manageable level.
● Awareness of high risk drugs such as potassium chloride and cytotoxic
agents.

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o EXAMPLE OF DISPENSING ERROR
• A physician writes an order for primidone (Mysoline) for a 12-
year old boy with a seizure disorder. Misreading the
physician’s handwriting, the pharmacist mistakenly fills the
order with prednisone.

• For 4 months, the boy receives prednisone along with his

seizure medications, causing steroid-induced diabetes.

• The diabetes goes unrecognized, and he dies from diabetic

ketoacidosis…

• Because the drug was LASA drug it leaded to Dispensing Error

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 ➢ ADMINISTRATION ERROR:
• A drug administration error may be defined as a discrepancy between the drug
therapy received by the patient and the drug therapy intended by the prescriber.

• It involves wrong patient, wrong route of administration, wrong drug, wrong dose,
wrong method, wrong time.
❖ CAUSES OF MEDICATION ERRORS:

• Lack of perceived risk

• Lack of available technology
• Lack of knowledge of the administration procedures
• Complex design of equipment.

❖ CONTRIBUTING FACTORS TO DRUG ADMINISTRATION

ERRORS:

• Failure to check the patient’s identity prior to administration

• Environmental factors such a noise, interruptions, poor lighting.
• Wrong calculation to determine the correct dose 15
 o EXAMPLE OF ADMINISTRATION ERROR
1. A critical care nurse tries to catch up with her morning medications
after her patient’s condition changes and he requires several
procedures.

• He is intubated, so she decides to crush the pills and instill them into
his nasogastric (NG) tube. In her haste to give the already-late
medications, she fails to notice the “Do not crush” warning on the
electronic medication administration record.

• She crushes an extended-release calcium channel blocker and

administers it through the NG tube. An hour later, the patient’s heart
rate slows to asystole, and he dies…because of Administration error

2. Instilling Eye Drops in wrong Eye.

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➢ ERRORS OF OMISSION:

• Failure to counsel the patient

• Failure to screen for interactions and contraindications
• Failure to administer an ordered dose to a patient before the next
scheduled dose, if any.

➢ WRONG TIME ERROR:

• Administration of medication outside a predefined time interval from

its scheduled administration time( This interval should be established
by each individual health care facility)

➢ UNAUTHORIZED DRUG ERROR:

• Administration to the patient of medication not authorized by a

legitimate prescriber for the patient. 17
➢ IMPROPER DOSE ERROR:

• Administration to the patient of a dose that is greater or less than the amount
ordered by the prescriber.
➢ TRANSCRIPTION ERROR:
▪ Transcription is a process of making an identical copy of prescription in the medical records. Error that
occurs during this process is known as Transcription Error.

▪ Several sheets of paper and stages from physician’s order to drug delivery may cause confusion and
add to the possibility of transcription errors.

➢ Wrong Dosage-Form Error:

• Administration to the patient of a drug product in a different dosage form than

ordered by the prescriber.

➢ Compliance Error:

• Inappropriate patient behavior regarding adherence to a prescribed medication

regimen. 18
➢ CATEGORISATION OF MEDICATION ERRORS
CATEGORY EVENT

1. A Circumstances or event that has a capacity to

cause error
2. B Error occurred but didn’t reach the patient.

3. C An error occurred that reached the patient but

did not cause any harm.
4. D An error occurred that reached the patient and
required monitoring to confirm that it resulted
in no harm to the patient and /or required
intervention to preclude harm.
5. E An error occurred that may haveCategory
contribute to
or resulted in temporary harm to the patient and
required intervention.

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 CATEGORY EVENT

6. F An error occurred that may have contribute

to or resulted in temporary harm to the
patient and required transfer to other
unit/critical care.

Category Event
7. G An error occurred that may have contribute
to or resulted in permanent harm of the
patient.
8. H An error occurred that required intervention
to sustain life.

9. I An error occurred that may have contribute

to or resulted in patient’s death.

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➢ STEPS TO BE TAKEN IN
PREVENTING MEDICATION
ERROR:

➢ Follow the rights of medication

administration:

✓ Right Drug
✓ Right Route
✓ Right Time
✓ Right Dose, Dosage
✓ Right Patient

Reference:

https://in.pinterest.com/pin/619385754978803566/
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✓ Be sure to read labels at least 3 times, during administration of the drug.
✓ Check the expiry date of the drug before administration.
✓ Be alert to usually large dosage or excessive increase in dosage ordered.
✓ When in doubt, check order with prescriber, pharmacist, literature.
✓ Double check all calculation, even simple calculation
✓ Read the leaflet of the drug carefully when giving new drug first time.
✓ Do not make assumptions of illegible orders.
✓ Do not accept incomplete orders and telephonic or verbal orders.
✓ Double check with a client who has allergies about all new drugs as they are added in
treatment plan
✓ Question a drug form used in unfamiliar way.
✓ Document all medication as soon as they are given.
✓ When you have made an error reflect on what went wrong.
✓ Attend in-service program that focus on the drug you commonly administer.

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➢ STEPS TO MINIMIZE MEDICATION ERROR

A. PRESCRIBER ACTIONS

B. PHARMACY (DISPENSING) ACTIONS

C. NURSE (ADMINISTRATOR) ACTIONS

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A) PRESCRIBER ACTIONS TO REDUCE MEDICATION ERRORS
✓ Stay current & knowledgeable concerning changes in medication &
treatment

✓ Utilize pharmacist consultation if available

✓ Ensure that drug orders are complete, clear, unambiguous & legible,
Including patient weight, dosage (mg/kg/dose or/day), frequency &
route of administration

✓ Avoid use of terminal zero e.g. use 5 rather 5.0

✓ Use a zero to the left of a zero ( use 0.2 rather .2 )

✓ Discuss medication changes with nursing & other staff & families

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B) PHARMACY (DISPENSING) ACTIONS TO REDUCE
MEDICATION ERRORS

✓ Independent double check orders both on calculation &

preparation

✓ Clarify confusing orders

✓ Checking for current patient drug allergy

✓ Dispense medication using unit-dose, ready to administration form

whenever possible

✓ Patient name, generic drug name, patient specific dose on all

labels

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C) NURSE (ADMINISTRATOR) ACTIONS TO REDUCE
MEDICATION ERRORS

✓ Double check medication calculations

✓ Verify drug order & confirm patient identity & weight before
administration

✓ Have access to drug information on all medications

✓ Familiar with the operation of medication administration device

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➢Pharmacist Role In Improving Medication
Safety:

1. Automation and Computerization of Medication use processes and

tasks:
• Examples include:
• The use of technologically and clinically sound computerized Drug -Information
Systems.

2. Independent Double-Check Systems:

• These are tools that can reduce the risk of errors if one person independently
checks another’s work
• The likelihood of two individuals making the same error with the same medication for
the same patient is quite small.

3. Staff Education:
It can be an important error-prevention strategy when it is combined with other
approaches that strengthen the medication-use system.

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➢ Conclusion:

❖ Medication Errors are preventable and can occur at any step in the
medication use process.

❖ High alert medications, especially those administered parenterally, have a

greater likelihood of being involved in harmful medication errors.

❖ The important thing to do after detecting medication error is correcting it &

make Report about it.

❖ To Prevent medication errors from happening again and enhance patient

safety by learning from failure of the health care system.

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➢ REFERENCE:
✓ https://www.slideshare.net/AnkitGaur18/medication-errors-ppt

✓ https://www.slideshare.net/maryline1979/medication-error-
25474916

✓ https://slideplayer.com/slide/5783469/

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THANK YOU
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