Medication Errors:
Causes & Prevention
Mrs. Amrita Sarkar
Lecturer
Burdwan Institute of Pharmacy
Definition
Medication errors is defined as any error in
the prescribing, dispensing, or
administration of a drug, irrespective of
whether such errors lead to adverse
consequences or not, are the single most
preventable cause of patient harm.
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Causes of Medication Errors
Missing patient information (allergies, age, weight,
pregnancy, etc.)
Missing drug information (updated references, etc.)
Drug name, label, packaging problem (look
alike/sound alike, faulty drug identification)
Environmental, staffing, workflow (lighting, noise,
workload, interruptions, etc.)
Lack of staff education;
Lack of Patient education (Lack on patient
consultation, non-compliance);
Lack of Prescriber knowledge
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Classification of Medication Errors
The medication error may be classified in to mistakes, slips, or
lapses.
Medication errors may also be classified according to where
they occur in the medication use cycle, i.e. at the stage of
prescribing, dispensing, or administration of a drug.
Types of Medication Errors
Prescribing Errors
Dispensing Errors
Drug administration Errors
Monitoring Errors
Compliance Errors
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1. Prescribing Errors
Prescribing of
Incorrect drug Errors in
a
selection for a quantity,
contraindicate
patient indication
d drug
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Contributing factors for
Prescribing Errors
Use of dangerous abbreviations (e.g. AZT has
led to confusion between Zidovudine and
Azathioprine)
Inadequate knowledge
Calculation errors
Uncommon and complicated dosage regimen
frequencies
Poor patient history taking
Different drug formulations available
Drug name confusion (Look alike Sound alike)
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Can you read this???
Neither can we!!! 7
Always use leading zeros for decimal points.
The order should have read:
Digoxin 0.5 mg
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Risk factors for prescribing errors
Work environment
Workload
Communication within the team
Physical and mental well being
Lack of knowledge
Organizational factors such as inadequate
training
Low perceived importance of prescribing
An absence of self awareness of errors
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Approaches for reducing
prescribing errors
Electronic prescription
Computerized physician order entry systems
Ensuring up-to-date reference sources.
Ensuring knowledge of a drug before prescribing.
Ensuring an accurate patient history is taken.
A zero should always precede expression of values
<1 e.g 0.9
Avoiding the use of abbreviations e.g. AZT, ISMN,
FeSO4,
Be aware of Look alike and sound alike (LASA)
products. 10
Electronic prescription
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Computerized Physician Order
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2. Dispensing Errors
Occur at any stage during the dispensing process (from
the receipt of a prescription to the supply of a
dispensed product to the patient).
Research estimates that 5% of all prescriptions are
dispensed improperly.
Reduce patient’s confidence on the pharmacist.
Confusion occurs primarily with drugs that have a
similar name or appearance. E.g. Lasix® (frusemide)
and Losec® (omeprazole)
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Administration Errors
Discrepancy between the drug therapy received by the
patient and the drug therapy intended by the prescriber
Administration errors account for 26% to 32% of total
medication errors.
Types:
1. Omission Error (e.g.: lack of stock)
2. Wrong dose error
3. Wrong route error (Left eye instead of Right)
4. Wrong dosage form
5. Wrong time error
6. Wrong administration technique (e.g. : Incorrect
manipulation of Inhalers ; Administration of expired
drugs; ) 14
Contributing factors to drug
administration errors
Failure to check Calculation
the patient’s Environmental
factors such a
to determine
identity prior to the correct
noise,
administration. interruptions, dose, where
Storage of look-a- poor lighting, more than
like preparations while one tablet is
side by side in undertaking the required.
the drug trolley. drug round. 15
4. Monitoring & Compliance Errors
Monitoring Errors: Monitoring errors are caused
by…
Failure to review a prescribed regimen for
appropriateness
Failure to use appropriate clinical or laboratory
data to assess the patients’ response to prescribed
therapy.
Compliance Errors: Compliance errors are
caused by inappropriate patient behavior regarding
adherence to a prescribed medication
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Avoiding medication errors
Perform the “five rights” of
medication administration every
time
Right patient (using two identifiers)
Right drug
Right dosage
Right time
Right route.
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Six Steps approached by
WHO for good prescribing
Evaluate & clearly define patient’s problem
Specify therapeutic objectives
Select appropriate drug therapy
Initiate therapy with appropriate details
Give information, instructions & warnings
Evaluate therapy regularly (e.g. Monitor treatment results)
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Role of Pharmacist
Refer back to doctor if any confusion
Basic knowledge of dosing regimens for commonly used drugs
Computer reminder for serious confusing name pairs to avoid
errors in prescription
Stickers of ‘Alert’ in areas where LASA drugs stored
In case of wrong prescription, pharmacist should not react in
front of patient
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Websites helps in
medication errors
LACT Epocrates electronic drug resource:
www.epocrates.com
FDA MedWatch:
www.fda.gov/Safety/MedWatch/default.htm
Institute for Safe Medication Practices:
www.ismp.org
MedlinePlus Drugs, Supplements, and Herbal
Information:
www.nlm.nih.gov/medlineplus/druginformation.
html
National Coordinating Council for Medication
Error Reporting and Prevention: 20
www.nccmerp.org
Thank You
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