One error, two error, three error… NO MORE! Keep calm and ... · BG presents to the ER after a MVA with a fractured femur. She has a history of Stage D COPD and is on the appropriate

$Page 1: One error, two error, three error… NO MORE! Keep calm and ... · BG presents to the ER after a MVA with a fractured femur. She has a history of Stage D COPD and is on the appropriate$
One error, two error, three error… NO MORE!Keep calm and prevent medication errors!

Steven Khelouss i , PharmDAssistant Professor of Pharmacy Pract ice

Wilkes Univers i ty Nesbitt School of Pharmacy

Vicky Shah, PharmD, BCPSAss istant Professor of Pharmacy Pract ice

Wilkes Univers i ty Nesbitt School of Pharmacy

Disclosure StatementSteven Kheloussi and Vicky Shah have no potential or actual conflicts of interest to

disclose.

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Describe the difference between a medication error and a close call or near miss

Evaluate inpatient and outpatient medication errors

List methods to prevent medication errors

Learning Objectives

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Definitions

Adverse Drug Reaction

• A noxious and unintended response to a medicine that occurs at NORMAL THERAPEUTIC DOSES used in humans for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiologic function

Drug Hypersensitivity

• Immunologic reaction

Adverse Drug Event

• Medication errors and overdoses

• Preventable

Geneva: World Health Organization. 2002;(2):5–6. http://apps.who.int/iris/bitstream/10665/67378/1/WHO_EDM_QSM_2002.2.pdf 4

Definitions

Serious Adverse Drug Effect

• Any untoward medical occurrence that occurs at any dose and results in death, requires hospital admission or prolonged hospital stay, results in persistent or significant disability, or is life threatening

Side Effect

• Any unintended effect of a pharmaceutical product occurring at NORMAL THERAPEUTIC DOSES and is related to its pharmacological properties.

• Effects are well known and expected

• Usually require little to no change in regimen to manage patient

Geneva: World Health Organization. 2002;(2):5–6. http://apps.who.int/iris/bitstream/10665/67378/1/WHO_EDM_QSM_2002.2.pdf 5

Adverse Drug Reaction Vs. Adverse Drug Event

Becker SC. PSNet: Patient Safety Network, National Coordinating Council for Medication Error Reporting and Prevention. 2015 Apr. 6

Take medication

Symptoms – Side effects

Injuries

Preventable:

Adverse drug event

Not Preventable:

Adverse drug reaction

Error?

Yes No

Impact and Burden

Panesar SS, et al. BMJ Qual Saf. 2016;25:544-53.Samp JC, et al. Pharmacotherapy. 2014;34(4):350-7.Lahue BJ, et al. Am Health Drug Benefits. 2012 Nov-Dec; 5(7): 1–10

• Difficult to define prevalence o No standardized error collection systems

o Studies vary significantly

• Annual estimateso Affect more than 7 million patients

o Contribute to 7,000 deaths

o Cost almost $21 billion

• ~4% of errors result in severe harm

• Average cost of a medication error is ~$89

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Classification of Medication Errors

Commission or omission

Amount of harm caused

Phase in distribution process

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Classification of Medication ErrorsCommission or Omission

Commission

Doing the wrong thing

Omission

Failing to do the right thing

Thomsen LA, et al. Ann Pharmacother. 2007 Sep;41(9):1411-26. 9

Classification of Medication ErrorsAmount of Harm Caused

Hartwig SC, et al. Am J Hosp Pharm. 1991 Dec;48(12):2611-6. 10

Classification of Medication ErrorsPhase in Distribution Process• Prescribing

• Order communication

• Product labeling, packaging, and nomenclature

• Dispensing and distribution

• Compounding

• Administration

• Education

• Monitoring

• Use

US FDA. Medication errors related to drugs. Updated 11/13/2017. https://www.fda.gov/drugs/drugsafety/medicationerrors/ 11

Case #1BG presents to the ER after a MVA with a fractured femur. She has a history of Stage D COPD and is on the appropriate medications for that disorder. Upon admission, she was placed on patient-controlled analgesia. At discharge, she is given two prescriptions for an equivalent dose as to what was received in the hospital:- Percocet 10/325 mg, one tablet every 6 hrs prn, #80- Oxycontin ER 30 mg, one tablet twice daily, #60

Has a prescribing error occurred?

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Med Errors in the Prescribing Phase• Not initiating appropriate therapies

• Initiating inappropriate medicationso Drug interactions

o Contraindicated medications

o High risk medications in the elderly (Beers Criteria, STOPP Criteria)

• Not discontinuing inappropriate medications

o Drugs without indications

Elden NMK, et al. Glob J Health Sci. 2016;8(8):243-251. 13

Med Errors in the Prescribing Phase• Incorrect drugo Medication, dosage form

• Incorrect strength

• Incorrect doseo Dose too high, dose too low

• Incorrect directionso Route

o Frequency

Thomsen LA, et al. Ann Pharmacother. 2007 Sep;41(9):1411-26.Elden NMK, et al. Glob J Health Sci. 2016;8(8):243-251.

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Preventing Prescribing Errors

Velo GP, et al. Br J Clin Pharmacol. 2009 Jun;67(6):624-8.Elden NMK, et al. Glob J Health Sci. 2016;8(8):243-251.

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Complete Past Medical History

Education

Double CheckElectronic Resources

Med Errors During Order Communication

Verbal Orders Written

Prescriptions

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Case #2YW is a 72 year old male who is rushed to the emergency room via ambulance due to cardiac arrhythmias caused by hypokalemia (Potassium = 1.5mg/dL). The physician calls the pharmacy to place an emergency order of IV potassium chloride of an initial infusion of 2 mEq/min, followed by another 10 mEq IV over 5 to 10 minutes. Due to the urgent need of attending to the patient, the physician hangs up right after placing the order. The pharmacist, who was in the middle of completing three different tasks did not have an opportunity to write the order down and attempted to place the order from memory.

What is wrong with this situation?

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Case #2Six hours later, the pharmacist is informed the patient has passed away from cardiac death caused by hypokalemia due to the patient not receiving appropriate treatment. The pharmacist had entered potassium chloride infusion of 2 mEq/min followed by 10mEq IV every hour instead of over 5 to 10 minutes. The pharmacist did not repeat or clarify the order with the physician, thus leading to the patient’s death.

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Verbal Orders

Mishearing the order

Hearing impairment

Background noise Misspeaking Mispronunciations Sound alike drugs

Wakefield DS, Wakefield BJ. Qual Saf Health Care. 2009 Jun;18(3):165-8. 19

Verbal Orders

• Unfamiliarity with the patient

• Confusion of patient data or patient

Misinterpreting the order

• Unapproved abbreviations or doses

Incorrectly transcribing

Failure to get clarification of orders

Failure to read the order back


Preventing Errors During Verbal Orders

Avoid verbal orders unless

neededDevelop guidelines

Read back the order!

Confirm authorization to complete verbal

orders

Documentation!!!

Medication events analysis and reporting in the Johns Hopkins Hospital nursing practice and organization manual. The Johns Hopkins Hospital Department of Nursing, Baltimore, MD. 8/13/2001. https://www.aao.org/asset.axd?ID=8E67D701-3FC5-4FD5-BA14-172C608949D4.

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Time to play a game!

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Can you read these RXs? Pharmacy Times. 2014 Sep 16. www.pharmacytimes.com/publications/issue/2014/sept2014/can-you-read-these-rxs-09-2014. 23




Written Prescriptions

Write in block letters, not cursive

Use the metric system

Avoid abbreviations

Leading/Trailing Zeros

Include all necessary

information on prescription

Be specific for PRN orders


Inappropriate AbbreviationsAbbreviation Intended Meaning Misinterpretation Correction

μg Microgram Mg (milligram) Use “mcg”

cc Cubic Centimeter Mistaken as “u” (units) Use “mL”

D/C Discharge or DiscontinuePremature discontinuation of

medicationsUse “Discharge” or

“Discontinue”

IU or U International Unit Mistaken as IV or 10 Use “units”

qd or QD Every day Mistaken as QID Use “daily”

qod or QOD Every other day Mistaken as QD Use “every other day”

SC, SQ, subq SubcutaneousSC mistaken for SL, SQ mistaken for 5 every, subq mistaken as sub q (every)

Use “subcut” or “subcutaneously”

> and < More than or less than Mistaken as opposite of intended Use “more than” or “less than”

List of error-prone abbreviations, symbols, and dose designations. ISMP. 2015. http://www.ismp.org/tools/errorproneabbreviations.pdf 28

Inappropriate Dose Designations

List of error-prone abbreviations, symbols, and dose designations. ISMP. 2015. http://www.ismp.org/tools/errorproneabbreviations.pdf

Dose Designations Intended Meaning Misinterpretation Correction

Trailing zero after decimal point(e.g. 1.0 mg)

1 mg10 mg if decimal point not

seenDo not use trailing zeros for doses

expressed in whole numbers

“Naked” decimal point (e.g. .5 mg)

0.5 mg5 mg if decimal point is

not seen

Use zero before a decimal point when the dose is less than a whole

unit

Drug and dose run together (e.g. Inderal40 mg or Tegretol300 mg)

Inderal 40 mgTegretol 300 mg

Inderal 140 mgTegretol 1300 mg

Place adequate space between the drug name, dose and unit of

measure

Large doses without properly placed commas (e.g. 100000 units)

100,000 units 10,000 or 1,000,000Use commas for dosing units at or above 1,000 or use words such as

100 thousand

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Look-Alike/Sound-Alike Drugs

List of confused drug names. ISMP. 2015. http://www.ismp.org/Tools/confuseddrugnames.pdf

Drug Name Confused Name

Actos Actonel

Allegra Viagra

Amiloride Amlodipine

Bicillin C-R Bicillin L-A

Bupropion Buspirone

Cycloserine Cyclosporine

Guaifenesin Guanfacine

Drug Name Confused Name

Tdap DTaP

Alprazolam Lorazepam

Celexa Celebrex

Brillinta Brintellix

Clonidine Klonopin

Folic Acid Folinic Acid

Humalog Humulin

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Look-Alike/Sound-Alike Drugs

• If medications are stored in the office or hospital, label with both generic and brand name if known

• Don't store drugs with similar names alphabetically. Instead, store them apart from each other or in different locations

• Provide both the generic and brand name in communications of drug orders

• Write the purpose for the medication on the prescription to help the pharmacist interpret the order accurately

List of confused drug names. ISMP. 2015. http://www.ismp.org/Tools/confuseddrugnames.pdf 31

Labeling, Packaging, and Nomenclature• Directions must be specifico “2 tablets twice daily” vs “2 tablets in the morning and 2 tablets in the evening”

• Use numbers instead of texto “3” vs “three”

• Avoid abbreviating drug nameso “APAP” or “ASA”

• Avoid error-prone abbreviations, dose designations

• Keep it patient friendly!

Principles of designing a medication label for community and mail order pharmacy prescription packages. ISMP. 2014 Dec 30. http://www.ismp.org/Tools/guidelines/labelFormats/comments/default.asp

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Time for another game!

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Same or Different?

Look-alike drugs lead to prescription errors. ABC News. abcnews.go.com/Blotter/slideshow?id=9981722SunPharma. https://www.sunpharma.com/node/120615

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Same or Different?


35

Same or Different?


36

Look-Alikes

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. Patient Safety and Quality Healthcare. 2016 Oct 3. https://www.psqh.com/analysis/paralyzed-by-mistakes-reassess-the-safety-of-neuromuscular-blockers-in-your-facility/2/

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Case #3LT picked up his prescription for tacrolimus 0.5 mg for preventing rejection of his liver transplant from your pharmacy. Several days later, you find out that the patient was hospitalized secondary to rejection of his transplanted liver.

What kind of dispensing errors could have caused this?

ISMP. Multifactorial Causes Of Tacrolimus Errors. ismp.org/newsletters/acutecare/showarticle.aspx?id=1173 38

Dispensing and Distribution Errors• Incorrect medication or strength

• Incorrect patient

• Incorrect quantity

• Incorrect dosage form

• Incorrect information on prescription label

• Expired or nearly expired drug

• Failure to dispense

Cheung KC, et al. Br J Clin Pharmacol. 2009 Jun;67(6);676-80. 39

Case #4Mary Brown comes in to pick up her prescriptions. She states, “Just give me whatever’s there, I’m in a hurry.” Being a long time customer of your pharmacy, you know she always picks up for her husband, Ernie, as well. You ring her out for both her and Ernie’s prescriptions and she’s on her way.

• Your pharmacy technician then says, “It’s so sad what they’re going through.”• You ask, “What do you mean?” • Your technician responds, “They got divorced a few months back.”

What are some potential consequences of dispensingthe wrong medications to Mary?

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Preventing Dispensing andDistribution Errors

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Confirm all information is

correct

Educate patients to look

for changes

Identify reasons for prior dispensing errors…

… and correct them!

Compounding Errors

CompoundingMixing

medicationsIV

compatibilities

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Case #5JP is an 8-month-old girl who was prescribed amoxicillin/clavulanate potassium suspension to treat an ear infection. The prescription was taken to the family’s local community pharmacy, where a stock medication bottle labeled with instructions to give the child a half teaspoon twice daily by mouth was dispensed. When the family arrived home, they measured a half teaspoonful of the powder and administered it to the girl. The girl was rushed to the emergency department, where she was treated for antibiotic overdose.

What do you think caused this overdose?

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Case #5

The pharmacy failed to mix the powder prior to dispensing the medication.

What are some ways that thiserror could have been prevented?

Gaunt MJ. Errors when preparing medications. Pharmacy Times. 2010 Oct 24. www.pharmacytimes.com/publications/issue/2010/october2010/medicationsafety-1010. 44

IV Compatibilities

Physical

• Change in color, odor, taste, viscosity or morphology

Chemical

• Change in breakdown of product

Therapeutic incompatibility

• Similar to drug interactions where efficacy of one drug is altered

Avoid the following combinations:

• Phenytoin + D5W → Crystallization

• Ceftriaxone + Calcium → Precipitation

Cousins DH, et al. Qual Saf Health Care. 2005;14:195. 45

Gianino MM, et al. Ann Ig. 2007;19(4):381-92. 46

Preventing Compounding Errors

Craven RF, Hirnle CJ. Chapter 30: Intravenous therapy. In: Craven RF, Hirnle CJ. Fundamentals of nursing –human health and function. 5. Edition, Philadelphia: Lippincott Williams & Wilkins. 2007; 604-639

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Proper labeling and instructions

Check compatibility of all

medications

Separate administration

times of IV medications

Use alternative medications if

needed

Use of flushes and filters to prevent

precipitation damage

Benefits of Education

Catch medication

errors

Reiterate proper use

Encourage appropriate

storage

Avoid preventable

adverse events

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Proper Education Competition

After a brief hospital stay for pneumonia, AL is ready to be discharged with a prescription for levofloxacin 500 mg, one tablet by mouth daily for 10 days. The physician asks the pharmacist to counsel on proper use before the patient heads home.

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Case #6WQ is a 79-year-old male admitted due to MRSA cellulitis and subsequently initiated on vancomycin. WQ has been consistently receiving 1000 mg every 12 hours at 9am and 9pm for three doses. Prior to his next dose, his blood was drawn to take his vancomycin trough level. The blood was drawn at 6am and the level was 10.1ng/dL. The pharmacist understood that the normal range is 10-20 and made no changes to the dose.

Is the pharmacist correct?What would you have done differently?

What else should also be monitored?

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Med Errors in the Monitoring PhaseFollow-up to ensure

• Patient is receiving benefit from medicationo Objective and Subjective

• No harm

• No changes preclude further use

• Adherence

• Accurate dosing

Elden NMK, et al. Glob J Health Sci. 2016;8(8):243-251. 51

Other ways to Prevent Med Errors• Don’t ignore “near misses”

• Don’t assumeo You won’t make another mistake

o Your mistakes are unique

• Extinguish common causeso Job stress, short-staffed, subject to time constraints, interruption during

dispensing, look-alike/sound-alike drugs

• Quality improvemento FOCUS-PDCA

• Report!

Wheeler JS, et al. Ann Pharmacother. 2017 Dec;51(12):1138-1141.US FDA. Medication error reports. Updated 8/2/17. www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htmCheung KC, et al. Br J Clin Pharmacol. 2009 Jun;67(6);676-80.

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ISMP Med Errors Reporting Program

53ISMP. ISMP National Medication Errors Reporting Program. ismp.org/orderforms/healthcaremerp.aspx

Wrapping up

Errors can happen to anyone at any

time

Each step in distribution process

is susceptible

Many medication errors are

preventable!

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Questions?

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Practice Case #1Which of the following prescriptions have potential for causing medication errors?• Digoxin 100 μg PO QD • Insulin Glargine 25U BID SC• Nystatin 5.0cc QOD PRN • Metformin 1000 mg by mouth twice daily

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Practice Case #2PS is 43-year-old male who was newly diagnosed with bipolar disorder. The physician initiated him on lithium 300 mg, 1 tablet by mouth 3 times daily. Due to an increase in patient appointments and upcoming holidays, the earliest appointment available for PS was six months later.

Three months after being on lithium, PS was rushed to the hospital due to seizures, confusion and subsequent coma.

What type of medication error has occurred?What could have happened to PS?

What could have been done differently?

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Documents

One error, two error, three error… NO MORE! Keep calm and ... · BG presents to the ER after a MVA with a fractured femur. She has a history of Stage D COPD and is on the appropriate