Where do errors occur

1
Where do errors occur?
2
Common causes of medication errors

• Human factors
• Systems
• Abbreviations
• Oral orders
• Look-alike and sound-alike drugs
• Dosage calculation
• At-risk population
• At-risk drugs

3
Human factors that lead to medication errors

• Fatigue/Lack of sleep
• Illness
• Drugs or alcohol
• Boredom
• Frustration
• Fear
• Stress

4
Systems factors that lead to medication errors

• Distractions
• Noise
• Heat
• Clutter
• Motion
• Lighting
• Unnatural workflow
• Poorly designed procedures or devices

5
Handwriting

• 25 of medication errors are the result of
  unintelligible orders (Jones, G)
• Texas jury blames bad penmanship for patient
  death physician to pay 225,000
• Pharmacist cannot escape liability by hiding
  behind a physicians unintelligible order

6
Abbreviations

• Abbrevs. also cntrbte. to errs., esp. if they
  might be interp. diff. by diff. h.c. provs. E.g.,
  QD has been interp. as QID when the . sep. the
  Q and D is carelessly writ. and looks like an
  I. The ltr. U inst. of the word UNITS may be
  interp. as a 0.

7
Oral Orders

• Drug orders given orally can be misunderstood,
  especially if they involve a sound-alike drug,
  for example
• Mellaril Elavil
• Paxil Taxol
• Prilosec Prozac
• Cerebyx Celebrex
• Oxycontin Oxycodone
• Hydroxyzine Hydralazine
• Alprostadil Alprazolam

8
Dosage errors

• Common and preventable dosage mishaps
• Incorrect calculations
• Incorrect notations
• Misinterpretations of the prescribed dose.
• Pediatric patients and geriatric patients are
  especially susceptible.

9
At greater risk from medication errors

• Very young and very old patients
• Patients receiving urgent, life-saving care
• Patients undergoing high-risk surgeries
• Patients on multiple medications
• Patients with multiple medication allergies
• Non-English speakers
• Anyone being discharged from the hospital

10
Drugs more likely to be involved in serious
medication errors

• Adrenergic agonists
• Anticoagulants
• Chemotherapy
• Chloral hydrate/midazolam liquid in children
• Concentrated electrolytes
• Insulin
• IV adrenergic antagonists
• IV digoxin
• Neuromuscular blocking agents
• Opiates
• Theophylline