Disclaimer The Pharmacy s Role in Reducing and Preventing Medication Errors: What are the Real World Issues? Vice President of Government Affairs & Pharmacy Relations Hospice Pharmacia * hp RxOptions Services of excellerx rgreene@excellerx.com 215-282-1674 1 I, Richard B. Greene, do not have any real or apparent commercial affiliations related to the content of this presentation. 2 Objectives Medication Errors Goal: provide pharmacists and pharmacy technicians with the skills necessary to identify medication errors and to develop methods for reducing the possibility of future errors. What are the real everyday challenges? * Explain confirmation bias * Identify Sound-Alike, Look-Alike, Packaging error challenges * Define the a non-punitive environment * * Also applies to pharmacy technicians 3 INCOMPETENT PEOPLE ARE, AT MOST 1% OF THE PROBLEM. THE OTHER 99% ARE GOOD PEOPLE TRYING TO DO A GOOD JOB WHO MAKE VERY SIMPLE MISTAKES AND IT S THE PROCESSES THAT SET THEM UP TO MAKE THESE MISTAKES. Dr. Lucien Leape Harvard School of Public Health 4 Communication issues are a top contributing factor in medicationrelated claims Drugs more likely to be involved in serious medication errors Adrenergic agonists Anticoagulants Chemotherapy Concentrated electrolytes Insulin IV adrenergic antagonists IV digoxin Chloral hydrate/ midazolam liquid in Neuromuscular children blocking agents Opiates Theophylline 5 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 Dangerous Abbreviations Do not use list Abbreviation Intended meaning Common Error Instead Use IU International units Mistaken as IV, 10 international unit QD, Q.D. Every day daily QOD, Q.O.D. Every other day every other day Trailing zero two milligrams Missed decimal 2 mg (2.0 mg) (read as ) Lack leading two-tenths Missed decimal 0.2 mg zero (.2 mg) milligrams (read as ) MS, MS04 MgS04 Confused for one another 8 Directions for Use The evening before the colonoscopy procedure, 3 tablets should be taken with 8 ounces of clear liquids every 15 minutes for a total of 20 tablets. The last dose will be 2 tablets. The day of colonoscopy procedure, (starting 3-5 hours before the procedure) 3 tablets should be taken with 8 ounces of clear liquids every 15 minutes for a total of 20 tablets. The last dose will be 2 tablets. 9 10 The Real World Dosage errors Common and preventable dosage mishaps Incorrect calculations Incorrect notations Misinterpretations of the prescribed dose. Pediatric patients and geriatric patients are especially susceptible. 11 12
Written Medication Orders: Illegible Handwriting Prescription Error Prevention 16% of physicians have illegible handwriting. 1 Common cause of prescribing errors. 2, 3, 4 Delays medication administration. 5 Interrupts workflow. 5 Prevalent and expensive claim in malpractice cases. 3 1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14; 5. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. 13 Legible Include complete information Patient-specific information express weight, volumes, and units using the metric system Drug names with caution Include the medication's purpose Avoid abbreviations Avoid decimals 14 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 physician s unintelligible order The Institute for Safe Medication Practices (ISMP) has called for eliminating handwritten prescriptions. http://www.ismp.org/msaarticles/whitepaper.html 15 16 Prescribing Prescribing 17 18
Prescribing and Dispensing Oral Orders Coumadin or Avandia? 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 19 indomethacin: Two 50 mg suppositories verses 250mg suppository 20 Verbal Orders Verbal Orders Nurse took a verbal order to: Increase LASIX to 40 an hour However, the prescriber never mentioned 40 mg per hour, as was intended The nurse misunderstood the order as 40 ml per hour For nearly 15 hours, the patient received 400 mg of furosemide per hour, a 10-fold overdose. 21 Verbal prescription: indomethacin Two 50 mg suppositories Or 250 mg suppository 22 Difference Between read-back vs. repeat-back The receiver of the order should write down the complete order or enter it into a computer Then the receiver should read it back Receive confirmation from the individual who gave the order Transcription of Orders Morphine 0.5 mg 23 24
Transcription of Order The letter U to indicate units The transcriber thought the order was for 44 units of Humalog instead of the 4 units it was supposed to be. The patient only received one overdose because when another nurse went to administer the medication the nurse told the patient the dose was 44 units of insulin and the patient said they only took 4 units at home. 25 Transcription of Order A patient with rheumatoid arthritis came to the pharmacy wanting to have a prescription for methotrexate filled. The pharmacy technician taking in the prescription asked the patient about allergy information and any other chronic conditions the patient had. The patient provided the information to the technician. The technician was not familiar with methotrexate and what it was for and how it is typically dosed in rheumatoid arthritis. The prescription was written illegibly. The pharmacy technician typed the prescription as 5 mg once daily. The prescription was actually for 5 mg once weekly. 26 Transcription of Order The pharmacy technician could not accurately read the prescription, but did not question it. If the technician had known that the medication is given once weekly in patients with rheumatoid arthritis this error may have been avoided. It is important for all pharmacy staff to be educated on the drugs they dispense. The better educated they are the less likely an error will occur. Conformation Bias IT AIN T WHAT YOU KNOW THAT GETS YOU IN TROUBLE, IT S WHAT YOU KNOW FOR SURE THAT AIN T SO Mark Twain 27 28 29 30
Confirmation Bias Definition: accept information that agrees with our hypothesis; Reject information that does not Practitioners see the name or dose that they are most familiar with and don t question the order 31 32 Confirmation Bias Types of Look-Alike Names THE PAOMNNEHAL PWEOR OF THE HMUAN MNID Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Handwritten orders Some pairs are only confused when handwritten Beginning of drug name is same metformin metronidazole tramadol trazadone Look-alike drug names hydralazine & hydroxyzine DOPamine & DOBUTamine morphine & HYDROmorphone Drug names with and without suffixes Immediate release and extended release products Amzanig huh? 33 34 Sound Alike Look Alike I know you believe you understand what you think I said, but I am not sure you realize that what you heard is not what I meant. (source unknown) 35 Examples of potential medication errors (nomenclature) The new drug Emend (aprepitant) {Chemotherapy- Induced Nausea and Vomiting} sounds like M-End Liquid (Brompheniramine/Codeine/Phenylephrine), {sinus congestion, runny nose, sneezing, and cough} which is made in Tennessee and often used in the surrounding area. They will sound the same on a called in prescription. 36
Look or Sound Alike Indication for Use Celebrex Celexa Chlorpromazine- Chlorpropamide Avandia Coumadin Lamictal Lamisil Isordil Plendil Zyprexa - Zyrtec Arthritis/Antidepressant Antipsychotic,other/ Diabetes Diabetes/Anticoagulant Seizures/Antifungal CHF/Blood Pressure Antipsychotic/ Antihistamine 37 38 Changes to Brand Names as a Result of Medication Errors Losec (confused with Lasix) is now Prilosec Levoxine (confused with Lanoxin) is now Levoxyl Mazicon (confused with Mivacron) is now Romazicon Pediaprofen (confused with Pediapred) is now Children s Motrin Altocor (confused with Advocor) is now Altoprev Reminyl (confused with Amaryl) is now Razadyne Omacor (confused with Amicar) is now Lovaza Key concepts in safeguarding medications Standardize order communication Establish and enforce safe ordering guidelines list of dangerous abbreviations or dangerous methods of expressing drug information eliminate use of non-standard symbols slash mark (/) seen as 1 or 7 Plus sign (+) seen as 4 And signs (&) seen as 2 @ seen as 2 ISMP MSA. July 26, 2007 Volume 12 Issue 15 39 40 Top 10 Medication Pairs Involved in Wrong Drug Errors Reported to PA-PSRS Morphine oral solutions Most overdoses occurred when solution is ordered, dispensed, and labeled by volume (ml), not dosage strength (mg) Patients received 5 ml of Roxanol (morphine) 20 mg/ml (100 mg) instead of the prescribed 5 mg (0.25mL) ISMP. (2004). Roxanol involved in another serious error. ISMP Medication Safety Alert! Community/Ambulatory Edition, 3, 1-2. PA-Patient Safety Reporting System Patient Safety Advisory. Vol. 4, No. 3; September 2007 41 42
Concentrated Morphine Solution Wrong Drug Errors Involving Morphine or HYDROmorphone Two nurses called in sick and the floor had 28 patients with only one agency (temporary staff) nurse to cover. Order for Morphine Sulfate 10 mg, the label read, Roxanol 20 mg/ml, 10 mg (0.5 ml) po q4h prn It was on the MAR between straight orders, not on the prn sheet. The patient received 200 mg (10 ml) dose instead of 10 mg (0.5 ml) dose and the error was not discovered until 26 hours later. The nurse charted 20 ml and signed that she gave 20 ml, then actually gave 10 ml. Of all wrong drug error reports that include morphine and/or HYDROmorphone, 36% involve a mix-up between those 2 drugs Of wrong drug reports that involve these 2 drugs 62% show morphine as the prescribed medication and HYDROmorphone given in error 71% of reports indicate that the errors occurred when these medications were obtained from unit stock Pennsylvania Patient Safety Reporting System. PA PSRS Patient Saf Advis. 2007;4(3):69-108 43 44 Example of potential medication errors (packaging) I am writing about my concern over 2 look alike labels for lidocaine. Lidocaine 1% and lidocaine 2% have similar labels. They are both blue and white and both have blue tops. They are both 20 ml. There have been a few instances where these drugs have been stocked incorrectly by pharmacy personnel due to the similar appearance of the labels. I don't know of any instances where patients were harmed, but the potential is definitely there. I suggest that the manufacturer change the color of one of the labels, so there is less chance of a mixup. 45 Pharmaceutical Industry One of the most frequent causes of pharmacy medication dispensing errors is failure to accurately identify drugs, most prominently due to lookalike and soundalike drug names. Leape et al. JAMA 1995; 274:35-43 46 Industry Standards Similar Packaging Develop and enforce standards for the design of drug packaging and labeling that will maximize safety in use. 47 48
Near Fatal Dose Similar Packaging Dennis Quaid Recounts Twins' Drug Ordeal Should have received Hep-Lock (10 units / ml) Were given Heparin (10,000 units / ml) Near Fatal Overdose Question: What was a contributory factor in this medication error? 49 50 Similar Packaging Similar Packaging 51 52 Similar Packaging Similar Packaging 53 54
Confusing Packaging Confusion of Products Physician recommended: Patient took: Active ingredient Bisacodyl...laxative Active ingredient Docusate sodium.stool softener 55 56 Label Identification Fleets Phosopho-Soda Packaged in 1 1/2, 3, & 8 oz Several patients ingested 8 oz 1 Death Several Injuries Result: no longer manufacturing of 8 oz 57 58 FDA focus on New Medications Why Pre-Marketing Labeling and Packaging Review? Vulnerable to confusion Names - Nomenclature Labeling and packaging Dosing Route of administration Special uses Contraindications 59 60
Practitioners and Healthcare Systems Medication errors have much more to do with breakdown in the system than with anyone s competency http://www.accessdata.fda.gov/psn/ 61 62 Systems of Medication Use Establish Non-punitive Environment Patient Information Drug Information References computer systems Formulary clinical pharmacists Communication Dynamics order and drug information Labeling, Packaging and Nomenclature Patient Education Device Acquisition, Use and Monitoring Environmental Factors Staff Competency and Education Drug Storage, Stock, and Distribution Quality Culture RM/QI efforts independent checks Infection Control 63 Drive out fear by reducing emphasis on punishment ADEs are always opportunities to learn about the system Punishment (e.g., sanctions, embarrassment, remedial education) drives errors underground where no one can learn from them, leaving system unchanged 64 Primary Principles in Error Reduction Reduce or eliminate the possibility of errors Make errors visible Minimize the consequence of errors Report and analyze internal errors Report errors externally Make Errors Visible Pharmacy IT systems/cpoe Computer alerts Warnings/reminders Double check systems Triggers (markers) Clinical Pharmacists (high risk patients) Bar coding 65 66
Thank you for your participation! Resources Pharmacy Quality Commitment www.pcq.net UW Center for Health Sciences Interprofessional Education http://interprofessional.washington.edu/ptsafety/ National Patient Safety Foundation www.npsf.org Joint Commission www.jcaho.com National Coordinating Council for Medication Error Reporting & Prevention www.jointcommission.org Institute for Safe Medication Practices www.ismp.org 68 The Pharmacy s Role in Reducing and Preventing Medication Errors: What are the Real World Issues? Vice President of Government Affairs & Pharmacy Relations Hospice Pharmacia * hp RxOptions Services of excellerx rgreene@excellerx.com 215-282-1674 69