Medication Safety and Error Prevention

Medication Safety and Error Prevention 16 LEARNING OBJECTIVES By the end of this chapter, students will be able to competently: 1. Explain the process for reporting errors. 2. Explain the difference between a medication error and a medication misadventure with regard to medication administration. 3. Use the five rights of medication administration to explain how medication errors may occur when: a. b. c. d. e. Dispensing or administering a medication to the wrong patient Dispensing or administering the wrong drug Dispensing or administering the wrong dose Administering a drug by the wrong route Dispensing or administering a drug with an incorrect dosing frequency (wrong time) 4. Discuss how medication misadventures may occur. 5. Explain how medication order entry and fill errors may occur in community and hospital pharmacies. 6. Examine strategies for preventing medication errors and misadventures resulting from: a. Order entry b. Fill process c. Pharmacy processes d. Storage practices e. Communication 7. Discuss how the pharmacy profession shares information to prevent medication errors. KEY TERMS Adverse drug event (ADE): A severe, unexpected patient reaction to medication administration. Medication error: Any preventable event that may cause or lead to inappropriate medication use or patient harm. Medication misadventure: An event in which a patient suffers harm after administration of medication for which a fill error occurred. A s is emphasized repeatedly throughout pharmacy technician course work, the primary goal of pharmacy technician practice is to support the pharmacist in the safe, efficacious dispensing of quality pharmaceutical products and services. Protecting the health, welfare, and safety of patients is the first priority of every pharmacist and pharmacy technician. Although relatively few medication errors occur, compared with the number of prescriptions filled each year, each of those errors represents a human life that was negatively affected, or maybe even ended, by a medication dispensing error. Every member of the pharmacy profession and the healthcare team must take extra care to practice behaviors that minimize the risk of a medication error. Unfortunately, errors do occur, and the 287

288 UNIT II Community Pharmacy Practice number continues to rise. When an error occurs, pharmacy and other healthcare personnel have an ethical and a legal obligation to report it. This is not just a measure of accountability for the individuals involved in the error; it is also a way to educate the rest of the pharmacy profession across the United States. Sharing cases of medication dispensing errors and resulting medication misadventures with other pharmacists and pharmacy technicians is helpful, because dispensing errors occur much more easily than one might think. Information sharing helps prevent that error in pharmacies in other cities or towns. This chapter also discusses how medication errors can be prevented in five key areas: Order entry Fill process Pharmacy processes Storage practices Communication Pharmacy technicians must consider the five rights of safe medication administration during the order entry, fill process, nonsterile pharmaceutical compounding process, unit-dose packaging process, medication unit inspection, cycle count, and sterile intravenous (IV) admixture, all of which they will perform in the course of their careers. Remember, the five rights are: Right patient Right drug Right dose Right route Right time This chapter first presents some basic definitions that apply to medication safety and errors. It then examines how medication errors and misadventures can occur when one or more of the five rights go wrong. Resources provided by national organizations (e.g., the Institute for Safe Medication Practices [ISMP]) for investigating, reporting, and preventing medication errors are also discussed. Defining Medication Errors and How They Occur The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has encouraged the healthcare professions to use the following standard definition of a medication error (NCCMERP, 2011 ): A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. 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. A medication error is an event that occurs because a prescription was filled incorrectly, at any point in the order entry, fill, compounding or dispensing process. A medication error becomes a medication misadventure when a patient is affected by that error. A medication misadventure caused by the pharmacy may be an event in which a patient suffers harm after administration of medication for which a fill error occurred. A medication misadventure caused by a patient or patient caregiver occurs when the medication is given or self-administered incorrectly. Medication errors occur for a variety of reasons. In a survey done in 2006, 80% of the 150 pharmacists surveyed reported that difficulty with product identification is probably the main reason patients and caregivers make medication errors. In 1996 and 1997, the Massachusetts Board of Registration in Pharmacy conducted a comprehensive study on the causes of medication errors. Survey responses indicated that the pressure of both internal and external stimuli or stressors contributed to or created ideal conditions for errors. Pharmacists who contributed to the study data gave the following as reasons for medication errors: Internal stressors Too many telephone calls No time to counsel

CHAPTER 16 Medication Safety and Error Prevention 289 External stressors Overload/unusually busy day Too many customers Lack of concentration No one available to double-check Staff shortage Similar drug names Illegible prescription Misinterpreted prescription Medication errors that occur as a result of staffing issues are common in both institutional and community pharmacies, particularly when the workflow is regularly heavy and stressful. Some common ways in which inadequate staffing creates dangerous opportunities for medication errors are: Increased workload, which often can result in a compromise in quality in favor of production Inadequate pharmacist availability for questions and assistance Short cuts that result in fewer multiple checks Overwork, which adversely affects staff members morale and general sense of commitment and accountability to job tasks Realistically, in a busy workplace, a heavy customer load results in profitability, so no business wants to eliminate its customer flow. Therefore, the workflow must be managed properly to ensure that quality is not compromised or abandoned in the pursuit of meeting workflow demands. Although good customer service in a retail industry generally is characterized by the provision of products and services in a timely manner, pharmacists and pharmacy technicians face the particular challenge of filling prescriptions as quickly as possible while ensuring that all necessary steps in the order entry and fill process are performed. PROCESS BREAKDOWN Regardless of whether internal or external stressors are present, all pharmacy technicians must recognize that every task associated with pharmacy practice should be well documented as a process in the pharmacy s standard operating procedures. A process is effective only when it is followed consistently; processes create a control in which an expected final product is produced when steps are followed in the same manner on a consistent basis. Deviation from the process, or process breakdown, can have serious workflow consequences, particularly in healthcare. In fact, an important way to research a medication error is to determine the point or points where a process breakdown led to the error. No simple solutions exist for easing or coping with the internal and external stressors of pharmacy practice. All pharmacy technicians must strive to perform their tasks with accuracy and safety as the first priority, and timeliness as a valuable second priority. Some additional common causes of medication errors, particularly in institutional pharmacies, include: Communication breakdown Incorrect transcription during a verbal order Illegible handwriting that is not verified for clarification Improper pass-down of information when multiple individuals process a particular order Inventory storage practices Internal and external products stored together Oral and injectable products stored together Difficult to read storage labeling Incorrect storage labeling Incorrect product locations Look-alike or sound-alike products stored close together Poor or inadequate lighting in drug storage areas Repetition/acquired blindness Short cuts or poor technique develop over time Recognizing the product shape and pulling the drug, without actually reading the label

290 UNIT II Community Pharmacy Practice BOX 16-1 Medication Errors Resulting from Breakdown in Adherence to the Five Rights of Medication Administration RIGHT PATIENT Similar or multiple names in a database without distinguishing patient identifiers Wrong patient s refill number selected RIGHT DRUG Wrong product with a similar name selected Wrong form of the right drug selected Wrong product selected because of illegible handwriting and misinterpretation Wrong product selected during the fill process Wrong information entered on the dispensing label RIGHT DOSE Wrong strength of an oral solid drug selected Wrong concentration strength of a liquid drug Wrong release rate of a product selected Use of an unapproved abbreviation that results in order entry error in drug dosing RIGHT ROUTE Wrong formulation of a drug selected (e.g., adult rather than pediatric formulation) Intravenous (IV) administration of an oral drug Oral administration of an IV drug Incorrect otic or ophthalmic product selected RIGHT TIME Wrong dosing frequency entered into pharmacy system and printed on dispensing label Wrong administration interval entered on an IV solution label Wrong IV drip flow rate entered and noted on an IV solution label STAT or one-time dose sent multiple times and administered multiple times by patient caregiver Scheduled dose not delivered at the right time, which may result in patient response to late dose, or patient caregiver may miss a scheduled dose as a result of delayed delivery RIGHT DOCUMENTATION Incorrect labeling of medication and/or products Improper pharmacy records Spelling and order entry errors result from lack of attention Overconfidence develops as a result of mastering a routine RELATING MEDICATION ERRORS TO THE SIX RIGHTS OF MEDICATION ADMINISTRATION Recall each of the six rights of medication administration that should be observed during the processes of medication order acceptance, review, entry, fill, and dispensing, administration, and distribution. Box 16-1 lists possible errors that can occur that relate to these six rights. How Medication Misadventures Occur Medication misadventures may or may not result from a medication error. Recall that a medication misadventure caused by the pharmacy may be an event in which a patient suffers harm after administration of medication for which a fill error occurred. A medication misadventure caused by a patient or patient caregiver occurs when the medication is given or self-administered incorrectly. The U.S. Agency for Healthcare Research and Quality (AHRQ) noted the following types of medication errors that result in an adverse drug event (ADE) (AHRQ, 2011 ): Missed dose Wrong technique Illegible order

CHAPTER 16 Medication Safety and Error Prevention 291 Duplicate therapy Drug-drug interaction Equipment failure Inadequate monitoring Preparation error Many misadventures occur as the result of a pharmacodynamic action of the drug, indicated by an ADE (a severe and unexpected patient reaction to medication administration). Because of the pharmacodynamics of drugs, the onset of an adverse reaction may be delayed or may occur within a short time after administration; it depends on the drug s onset of action. Examples of medication misadventures that occur as the result of a severe, unexpected reaction include: Adverse drug reactions: Unexpected; more serious than a side effect Allergic drug reactions: Caused by known or unknown drug, food, or environmental allergy Drug-drug interactions: Often result from the use of drugs from multiple therapeutic classes; over-the-counter (OTC) drugs that affect prescription drugs; or poor drug therapy monitoring by the pharmacist or other healthcare providers Medication misadventures may also occur as a result of a patient s lack of knowledge and understanding of the medication. Some patient-related causes of medication misadventures are: Noncompliance with the prescribed regimen Limited health literacy Lack of necessary patient education and drug therapy monitoring One of the best ways to prevent misadventures that occur as a result of misunderstanding is to ensure that patients receive medication counseling from a pharmacist. Strategies for Ensuring Medication Dispensing Safety and Error Prevention At this point you have studied a variety of scenarios that create opportunities for medication fill errors. By now you may realize that even when a pharmacy technician is well trained, competent, and has a good understanding of workflow processes, a breakdown of those processes can occur as a result of internal or external stressors (or both). However, you can get these processes back on track. Preventing medication errors requires commitment and focus. Let s examine strategies for preventing medication errors in the following key areas: Order entry Fill process Pharmacy processes Storage practices Communication ORDER ENTRY Eliminate errors caused by poor handwriting by using a computerized order entry system, rather than handwritten order entry. Pharmacists can practice read-backs during telephone verbal order transcription for confirmation and clarification. Pharmacists can discourage the use of high-risk abbreviations by prescribers ( Table 16-1 ). Ask the prescriber to spell it out instead. Verify the original order during transcription; if necessary, call back the prescriber for clarification. Verify the accuracy of labels before filling the prescription. FILL PROCESS Gather materials first. Read the label twice. Double-check ingredients before filling the prescription (Figure 16-1 ). Check the product by name, strength, and National Drug Code (NDC) number during the fill process. Avoid distractions and complete a fill before moving to another task.

292 UNIT II Community Pharmacy Practice TABLE 16-1 Dangerous Medication Abbreviations * Abbreviation Intended meaning Common error U Units Mistaken as a zero or a four (4), resulting in overdose. Also mistaken for cc (cubic centimeters) when poorly written. µg Micrograms Mistaken for mg (milligrams), resulting in an overdose. Q.D. Q.O.D. Latin abbreviation for every day Latin abbreviation for every other day The period after the Q has sometimes been mistaken for an I, and the drug has been given QID (four times daily) rather than daily. Misinterpreted as QD (daily) or QID (four times daily). If the O is poorly written, it looks like a period or an I. SC or SQ Subcutaneous Mistaken as SL (sublingual) when poorly written. T I W Three times a week Misinterpreted as three times a day or twice a week. D/C Discharge; also discontinue Patient s medications have been prematurely discontinued when D/C (intended to mean discharge ) was misinterpreted as discontinue, because it was followed by a list of drugs. HS Half strength Misinterpreted as the Latin abbreviation HS (hour of sleep). cc Cubic centimeters Mistaken as U (units) when poorly written. AU, AS, AD Latin abbreviation for both ears, left ear, and right ear, respectively Misinterpreted as the Latin abbreviation OU (both eyes); OS (left eye); OD (right eye) IU International Unit Mistaken as IV (intravenous) or 10 (ten) MS, MSO 4, MgSO4 Confused for one another Can mean morphine sulfate or magnesium sulfate * As designated by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). FIGURE 16-1 Double-check the ingredients of all prescriptions before they are filled. (From Hopper T: Mosby s pharmacy technician: principles and practice, ed 3, Philadelphia, 2011, Saunders.) Attach the appropriate auxiliary labels. Use charts and reference materials; do not work from memory. PHARMACY PROCESSES Staffing shortages are a reality; pharmacists and pharmacy technicians must learn to establish good workflow processes to compensate for understaffing.

CHAPTER 16 Medication Safety and Error Prevention 293 Never compromise good filling practices for production; work that must be done twice because of fill errors is inefficient and unproductive. Do not allow bad habits or poor attitudes to take root; be responsible for your own work. STORAGE PRACTICES Notify a pharmacist if poor lighting is an issue; you are probably not the first person to notice. Use TALLman LeTTering: In tall man lettering, key letters or syllables are noted in upper case, which helps distinguish between drugs with similarly spelled names. Store look-alike/sound-alike products in separate areas and post signs or labels to alert and warn staff members. COMMUNICATION Pharmacists and pharmacy technicians can help prevent medication errors and misadventures by learning from their mistakes. The profession of pharmacy cannot treat medication errors and misadventures as dirty little secrets; they must be openly and honestly shared with the rest of the healthcare community. The goal is to prevent another member of the profession from committing that same or a similar error and perhaps harming a patient. Not only is medication error reporting the right ethical decision, it also helps protect the health, welfare, and safety of patients across the pharmacy profession. The following publications carry information on medication errors and misadventures and how to report them: ISMP Medication Safety Alert! (newsletters) FDA Drug Safety Newsletter AHRQ has established the following measures to help prevent medication errors that result in ADEs: Use the U.S. Food and Drug Administration s (FDA s) Medwatch program to report serious ADEs. Improve incident reporting systems. Create a better (less punitive or discipline-driven) atmosphere to encourage more consistent ADE reporting. Rely more on pharmacists to advise physicians on medication therapy. Put increased emphasis on promoting healthcare provider education on medication use. Improve nursing medication administration and monitoring systems. Institute for Safe Medication Practices: A Resource for Error Reporting and Information and Resource Sharing The ISMP is a not-for-profit organization dedicated to educating the healthcare community, providers and patients alike, in safe medication practices and ways to prevent and protect themselves from medication errors. Several publications are available to practitioners that highlight errors that occur in specific areas of patient care, such as acute care (for the cardiac and general intensive care units) and ambulatory care (for community pharmacies). A nursing publication, Nurse Advise-ERR, is specifically designed to provide information about medication administration and ways to prevent errors during administration. The publication Safe Medicine is designed for consumers and provides information on ways patients can help prevent medication errors and misadventures through communication with their caregivers and pharmacists and through sources of healthcare education. ERROR REPORTING Pharmacy Reporting When an error occurs, the pharmacy files a detailed report with the U.S. Pharmacopeia/Institute for Safe Medication Practices (USP-ISMP) Medication Errors Reporting Program (MERP). Depending on the nature of the error, ISMP follows up when appropriate.

294 UNIT II Community Pharmacy Practice! TECH ALERT! Accountability by the pharmacy often prevents lawsuits. Individual Reporting When an error occurs, time is often a critical factor in reporting, particularly for contacting the patient to prevent the individual from administering the incorrect prescription fill. Personal accountability is a must, regardless of the implications for disciplinary action. When a pharmacy technician discovers an error, he or she must notify the pharmacist in charge or a staff pharmacist immediately. The pharmacist then contacts the patient to inform the person of the error and takes steps to retrieve the misfilled product and/or provide the patient with medical advice if he or she has already administered the wrong medication. All individuals involved in the medication error should complete any necessary internal documentation, providing as much detail as possible. Chapter Summary Medication errors are part of the reason healthcare costs continue to rise. All members of the pharmacy profession must consistently practice behaviors that minimize the risk of a medication error. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication misadventures may be caused by a pharmacy or by a patient. Medication errors that occur as a result of staffing issues are common to both hospital and community pharmacies, particularly when the workflow is regularly heavy and stressful. Common causes of medication errors, particularly in hospital pharmacies, may include communication breakdown, poor inventory storage practices, and repetition/acquired blindness. Inventory storage practices may create opportunities for medication selection or fill errors, or both. Acquired blindness occurs when a person relies on the color or size of packaging they are accustomed to seeing, rather than actually reading the package labeling. Errors caused by handwriting can be eliminated through the use of computerized order entry systems instead of handwritten order entry. Pharmacy technicians should review their habits and practice improvements that help prevent medication errors. Publications concerned with the reporting of medication errors and misadventures include Pharmacy Today, U.S. Pharmacist, ISMP Medication Safety Alert! newsletters (and other newsletters), and the FDA Drug Safety newsletter. The Institute for Safe Medication Practices (ISMP) is a not-for-profit organization dedicated to educating the healthcare community, providers and patients alike, in safe medication practices and ways to prevent and protect themselves from medication errors. When an error occurs, the pharmacy files a detailed report with the USP-ISMP Medication Errors Reporting Program (MERP). Depending on the nature of the error, ISMP follows up when appropriate. When a pharmacy technician discovers an error, he or she must notify the pharmacist in charge or a staff pharmacist immediately. The pharmacist contacts the patient to inform the person of the error and takes steps to retrieve the misfiled product and/or provide the patient with medical advice if he or she has already administered the wrong medication. All individuals involved in the medication error should complete the necessary internal documentation, providing as much detail as possible.

CHAPTER 16 Medication Safety and Error Prevention 295 TECHNICIAN S CORNER 1. How does process breakdown increase the risk of a medication error? 2. Give an example of an error that may occur as a result of poor adherence to verifying the right patient. 3. What steps should a pharmacy technician take when he or she discovers that a medication error has occurred? Bibliography Agency for Healthcare Research and Quality (AHRQ). (2001, March ). Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. Retrieved 8/17/2011, from www.ahrq.gov/qual/aderia/aderia.htm# MedicationErrors Gianutsos, G. (2008, December 1 ). Identifying Factors That Cause Pharmacy Errors. Retrieved 8/15/2011, from www.uspharmacist.com/continuing_education/ceviewtest/lessonid/105916 / Institute for Safe Medication Practices. (2011 ). ISMP Medication Safety Alert! Newsletters. Retrieved 8/16/2011, from http://ismp.org/newsletters/default.asp. Massachusetts Office of Health and Human Services. (2011 ). Reasons for Prescription Errors: Medication Error Study Results. Retrieved 8/15/2011, from www.mass.gov/?pageid=eohhs2terminal&l=8&l0=home&l1= Provider&L2=Certification%2c+Licensure%2c+and+Registration&L3=Occupational+and+Professional&L 4=Pharmacy&L5=Medication+Error+Prevention&L6=Medication+Error+Study&L7=Results+of+the+ Medication+Error+S National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). (2011 ). About Medication Errors. Retrieved 8/17/2011, from www.nccmerp.org/aboutmederrors.html Pharmacy Times. (2006, August 1 ). Study Looks into Rx Drug Errors Retrieved 8/17/2011, from www. pharmacytimes.com/publications/issue/2006/2006-08/2006-08-5742 / USA Today. (2009 ). A Prescription s Path through a Pharmacy. Retrieved 8/16/2011, from www.usatoday.com/ money/graphics/rx_error/flash.htm