More Presentations from from Dr.Naina Mohamed Pakkir Maideen
ØAny preventable event which may lead to inappropriate medication use or patient harm is termed Medication Errors (MEs).
Ø Major
causes of MEs include…
ª Missing
patient information
ª Missing
drug information
ª Miscommunication
of drug order
ª Drug
name, label, packaging problem
ª Drug
storage or delivery problem
ª Drug
delivery device problem
ª Environmental,
staffing, workflow
ª Lack
of staff education
ª Lack
of Patient education
ª Lack
of Physician knowledge
Ø Types
of MEs include…
§ Prescribing
Errors
§ Dispensing
Errors
§ Drug
administration Errors
§ Monitoring
Errors
§ Compliance
Errors
Ø Contributing
factors of Prescribing Errors include…
o Inadequate
knowledge
o Calculation
errors
o Uncommon
dosage regimen frequencies
o Complicated
dosage regimens
o Poor
patient history taking
o Use
of multiple dosage forms per dose
o Use
of abbreviations
o Mental
slips
o Lack
of adequate resources
o Different
drug formulations available
o Excessive
interruptions while involved in writing prescriptions or orders
o Illegible
handwriting
o Drug
name confusion (Look alike Sound alike)
o Inappropriate
use of decimal points
o Use
of verbal orders.
Ø Methods
to minimize Prescribing errors include…
¨ Ensuring
up-to-date reference sources.
¨ Use
of computerised physician order entry.
¨ Ensuring
knowledge of a drug before prescribing.
¨ Ensuring
an accurate drug history is taken.
¨ Printing
the drug name and patient details clearly on the prescription
¨ Including
all details of drug therapy i.e. name of drug, dose, directions, duration of therapy
¨ Avoiding
the use of abbreviations e.g. AZT, ISMN, FeSO4, U
¨ Being
aware of Look-alike and sound alike (LASA) products.
Ø Contributing
factors of Dispensing Errors include…
vConfusing
the name of one drug with another.
vTwo
or more drugs have a similar appearance or similar name
(look-a-like/sound-a-like)
vSelection
of the wrong strength/product.
vLack
of knowledge on new medicines.
vUse
of outdated and/or incorrect references.
vPoor
dispensing procedures with inadequate checking.
vUnreasonable
workloads.
vPoor
housekeeping standards.
vDistractions
and interruptions.
vDispensing
unfamiliar products.
vDispensing
before seeing a written order.
vThe
use of computerized labelling
Ø Methods
to minimize Dispensing errors include…
· Ensuring
a safe dispensing procedure.
· Using
different brands or separating LASA (Look alike and Sound alike) products.
· Focusing
on the task in hand.
· Keeping
interruptions to a minimum.
· Maintaining
workload at a safe and manageable level
· Being
aware of high risk drugs (HAM) e.g. Hypertonic Electrolytes (Potassium
chloride, Calcium chloride, Magnesium Sulphate), cytotoxic agents, IV Insulin.
· Introducing
good housekeeping practices.
Ø Contributing
factors of Administration Errors include…
ª Failure
to check the patient’s identity prior to administration.
ª Storage
of look-a-like preparations side by side in the drug trolley.
ª Environmental
factors such as noise, interruptions and poor lighting while undertaking the
drug round.
ª Incorrect
calculation to determine the dose.
Ø Methods
to minimize Administration errors include…
§ Checking
patients’ identity.
§ Having
dosage calculations checked independently by another healthcare professional
before the drug is administered.
§ Having
the prescription, the drug and the patient in the same place so they can be checked
against one another.
§ Ensuring
that medication is given at the correct time.
§ Minimizing
interruptions during drug rounds.
Ø Reasons
for underreporting of MEs…
¨ Disagreement
over the definition of an error
¨ Staff’s
disability to recognize an error has occurred
¨ Staff’s
belief that the error does not warrant reporting
¨ Staff’s
belief that she/he has not committed the error
¨ Staff’s
embarrassment
¨ Staff
fear for the reputation on of their service or unit
¨ Staff’s
fear of punishment/disciplinary actions
¨ Degree
of reporting effort/ time to complete reports
¨ Wrong
reporting time
¨ Local/unit’s
culture
¨ Confusing
reporting mechanisms, policies, or procedures
