Preventing Medication Errors

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Preventing Medication Errors

• August 2009
• Joe Manganelli, PharmD, MPA, RPh

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Objectives

• Define medication errors
• Discuss financial impact- medication errors
• Factors that contribute to medication errors
• Some causes of medication errors
• Groups most at risk
• Prevention of medication errors

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Definition

• A medication error is any preventable event that
  may cause or lead to inappropriate medication use
  or patient harm.
• 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 education
  monitoring and use.
• National Coordinating Council for Medication
  Error Reporting and Prevention (NCC MERP)

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The Problem

• Medication errors continue to be one of the
  most frequent causes of preventable harms in
  health care.
• Ambiguous medical notations are one of the most
  common and preventable causes of medication
  errors.
• Drug names, dosage units, and directions for
  use should be written clearly to minimize
  confusion.

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Statistics

• Institute of Medicine's (IOM) report, Preventing
  Medication Errors estimates that 1.5 million
  Americans are harmed by preventable adverse drug
  events each year, and hospitalized patients
  suffer an average of 1 medication error per day.
  
• Fortunately, most medication errors have little
  potential for harm, but every error is
  potentially tragic and costly.

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IOM Report-To Err is Human

• Noting that at least 1 in 4 of these errors is
  preventable, the IOM called on pharmacists,
  physicians, and government officials to take
  steps to reduce the rate of medication mistakes.
  To address the problem, the report called on the
  government to speed electronic prescribing by
  encouraging compatibility among the varied
  computer programs used by doctors, hospitals, and
  drugstores.

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IOM Report- To Err is Human

• Suggested stronger oversight by the FDA to
  address safety issues connected with drug
  packaging and labeling, similar named drugs and
  post marketing surveillance by doctors and
  pharmacists.

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Financial Impact

• On a per patient basis, a single serious drug
  error can add more than 8750 to the average
  hospital bill.
• Treating injuries caused by medication errors
  costs more than 3.5 billion a year in hospitals
  alone.

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Financial Impact

• Medication error litigation can result in
  compensation awards.
• CMS- Medicares stance on medical errors
• Effective October 2008, Medicare no longer paying
  to treat preventable medical errors.

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Contributing Factors

• Volume of prescriptions dispensed continues to
  rise
• Increased pharmacist workload
• Short staffing
• Not enough time to counsel patients
• Discussing the drug, its indication and how it is
  taken should be a final check

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No simple solution

• Computer Systems
• Can prevent errors
• Can cause errors
• A culture of safety should be encouraged so that
  staff is willing to discuss strategies in
  reducing errors
• Identify prevent potential computer-entry errors

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Research

• A study found that 57 percent of medication
  errors made in family physicians' offices could
  have been prevented by electronic medical records
  (EMR)or computerized physician order entry
  (CPOE).

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The Medication Process

• Medication errors often occur in one or more of
  the following medication stages
• Prescribing / Transcribing
• Dispensing / Distribution
• Administration
• Incomplete data poses risk for medication errors
• Unknown allergies, other drugs, previous
  diagnoses
• Errors with computer entry include
• Omission of drug, Improper dose or quantity

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Causes of Medication Errors

• Abbreviations
• ISMP has identified error-prone abbreviations.
  Some examples include
• AS, AD, AU for OS, OD, OU
• QD for QID, QOD for QID
• U or IU for 0 or 10, or IV
• Bad handwriting
• Verify illegible orders

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LASA Drugs

• Look Alike- Sound Alike Drugs
• It has been reported that up to 25 of all
  reported errors are linked to LASA confusion
• Read Rx back to prescriber to verify
• include the drugs purpose/ indication
• Affix name alert stickers to bins where LASA
  drugs are stored
• store drugs separately

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Examples of LASA drugs

• Aricept - Aciphex
• Actos- Actonel
• Celebrex - Celexa -Cerebyx
• Darvon - Diovan
• hydroxyzine - hydralazine
• Lasix - Luvox
• Paxil Plavix
• Prednisone - Primidone

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LASA drugs examples

• Navane- Norvasc
• Novolin- Novolg, Humulin Humalog
• (one can be selected for the other on a computer
  screen)
• Tramadol Trazodone
• Vincristine Vinblastine
• Wellbutrin SR- Wellbutrin XL
• (use of suffixes can cause confusion)

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Groups Most at Risk

• Healthcare literacy and cultural competency
• People with low health literacy have a greater
  number of medication errors
• Geriatric patients
• The elderly take more medications and at a higher
  risk for medication errors
• Many medications should be avoided by elderly
  patients

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Health Literacy

• Some medication errors occur because patient
  misuse of a drug
• poor understanding of the directions for proper
  product use
• Instructions should be delivered in a culturally
  sensitive format
• Pharmacies should use auxiliary stickers with
  pictures, such as for the eye, for the ear.

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Transitions of Care

• The potential for medication errors increases
  when patients transition in the healthcare system
  or return home.
• Accurate and complete medication reconciliation
  can prevent numerous prescribing and
  administration errors.

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Transitions of Care

• Use of a patient medication list is advised
• Include start and stop dates
• Reconcile pre-admission list to discharge list.
  Follow-up on discrepancies.

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Transitions of Care

• Develop list of medications currently taken
• Develop list of medications prescribed
• Compare the two lists
• Make clinical decisions comparing the two lists
• Communicate findings to practitioner and patient
• Medication reconciliation errors 66 occurred
  during transfer to another level of care, 22
  occurred during admission, 12 at discharge.
• JCAHO Sentinel Event Alert Issue 35, January 2006

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Medication Reconciliation

• Medication reconciliation is the process of
  comparing a patients medication orders to all of
  the medications that the patient has been taking.
  This reconciliation is done to avoid medication
  errors such as omissions, duplications, dosing
  errors or drug interactions.
• Joint Commission National Patient Safety Goal 8-
  a discharge list of medications should be given
  and discussed with the patient.
• Route, frequency and reason for use

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The role of working conditions

• Workflow design
• Review Rx process from beginning to end
• Physical environment
• Lighting, heat, noise
• Organizational factors
• Strive for a distraction-free work station,
  especially for prescription verification

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Prevention of Medication Errors

• Utilizing pharmacists as integral members of the
  patient care team as experts in medication-use
  safety and quality.
• Encouraging patients to keep an up-to-date list
  of all their medications
• Consulting/counseling with patients about their
  medications
• Promote a culture of safely in healthcare
  organizations- additional training?

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Prevention of Medication Errors

• Barcoding of medications can reduce hospital
  pharmacy dispensing errors that typically involve
  the incorrect medication, strength, or dosage
  form. Barcoding implementation was cost
  effective.
• Medication errors can be reduced by electronic
  medical records and computerized physician order
  entry.
• Maviglia, S.M., Yoo, J.Y., Franz, C., and others.
  (2007, April). "Cost-benefit analysis of a
  hospital pharmacy bar code solution." Archives of
  Internal Medicine 167, pp. 788-794.

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Prevention of Medication ErrorsPatient
Instructions

• Keep an UPDATED list of all medications taken,
  including Rx, OTCs, nutritionals.
• Ask to clarify anything not understood, or if
  anything looks different on refill.
• Variation in generic drugs
• Request written information on drug products.

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Patient Instructions

• Find out if any medications, food or beverages
  should be avoided (eg allergies).
• Telling your healthcare provider how you actually
  take your medication, especially if this is
  different that the originally prescribed
  directions.

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Patient Instructions

• Be safe. Be sure. Read the label.
• Check your name
• Check the directions
• Check any warnings
• Call Poison Control if needed

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Preventing Errors

• Bottle labels contain the shape and color of the
  pills
• Keep drug information up- to- date
• Triple check prescriptions before dispensing
• Avoid ambiguous abbreviations

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Preventing Errors

• Recent FDA action
• New warning on Botox, Myobloc and similar
  products about the possibility of life
  threatening breathing and swallowing problems.
• FDA is changing the generic names for both
  products to avoid medication errors
• Botox- onabotulinumtoxinA
• Myobloc- rimabotulinumtoxinB

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Pharmacist Survey

• Drug Topics, July 2009 Pharmacist-Driven
  initiatives- 4 errors per 250 scripts
• Counseling- provides an essential safeguard
  against medication errors.
• Better Time Management- less time multi-tasking -
  important to accurate drug dispensing
• Taking breaks- reduces fatigue, prevents stress
  related errors
• Filling Technology-bar coding minimizes errors

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Summary

• Preventing medication errors
• Review / improve workflow, medication processes
• consider use of barcodes
• computerize prescribing
• Pay attention to LASA drugs
• Avoid unapproved abbreviations
• Medication reconciliation- transitions of care
• Counsel patients

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References

• Grace M. Kuo, Pharm.D., Robert L. Phillips, M.D.,
  Deborah Graham, M.S.P.H., and John M. Hickner,
  M.D., in Quality and Safety in Health Care 17,
  pp. 286-290.
• Agency for HealthCare Research and Quality
  www.ahrq.gov
• Institute for Safe Medication Practices
  www.ismp.org
• Food and Drug Administration www.fda.gov/cder
• The Institute of Medicine www.iom.edu

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References, continued

• Am J Health-Syst Pharm Vol 66 May1, 2009
  www.ashp.org
• Using medication reconciliation to prevent
  errors. The Joint Commission. www.jointcommission.
  org/sentinelevents
• Center for Safety and Clinical Excellence,
  Cardinal Health www.cardinalhealth.com
• www.safemedication.com
• www.nccmerp.org
• www.1-800-222-1222.info poison prevention tips

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Thank you!

• Questions?