MEDICATION ERROR
What is a medication error?
According to National coordinating council for medication error reporting and prevention (NCC MERP) defines a medication error as “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 health care
professional, patient or consumer. such events may be related to professional practice,
healthcare products, procedures and systems including prescribing, order
communication, product labeling, packaging and nomenclature, compounding, dispensing,
distribution, administration, education, monitoring, and use.”
Categories of errors
a) NO
ERROR
CATEGORY A
Events that can cause an error
b) ERROR,
NO HARM
CATEGORY B
An error occurred but
it did not reach the patient
CATEGORY C
An error occurred
that reached the patient but did not cause any harm to the patient.
CATEGORY
D
An error occurred that reached the patient
and monitoring is needed to confirm that it did not cause any harm to the
patient.
c)
ERROR, HARM
CATEGORY E
An
error occurred - temporary harm - intervention is necessary
CATEGORY
F
An
error occurred - temporary harm to the patient - prolonged hospitalization
CATEGORY
G
An
error occurred - permanent patient harm
CATEGORY
H
An
error occurred - required intervention to sustain life.
d)
ERROR, DEATH
CATEGORY
I
An
error occurred that resulted in the patient’s death.
Types of medication errors
Ø
Omission
Ø
Prescribing
Ø
Wrong time
Ø
Unauthorized drug
Ø
Improper
dose
Ø
Administration errors
Ø
Monitoring errors
Ø
Compliance errors
Causes
of medication errors
A)
Factors associated with healthcare professionals
Ø Lack of
drug knowledge & experience
Ø Lack of
knowledge of the patient
Ø Inadequate
perception of risk
Ø Lack of
therapeutic training
Ø Poor
communication
B)
Factors associated with patients
Ø Patient
characteristics
Ø Past
medical history
C)
Factors associated with the work environment
Ø
Workload
Ø
Lack of standardized protocols
D) Factors associated with medicines
Ø
Naming of medicines
Ø
Labeling and packaging
E) Factors associated with tasks
Ø Repetitive systems (ordering, processing, and authorization)
Ø Patient
monitoring
F) Factors associated with computerized information systems
Ø Difficult
processes for generating first prescriptions
Ø Lack of
accuracy for patient records
Ø Inadequate
design that allows for human error
Table:1 dangerous abbreviation which cause errors
|
Abbreviation |
Intended
meaning |
Common
error |
|
U |
Units |
Mistaken as a zero or a four (4) &
cc (cubic centimeters) |
|
Μ G |
micrograms |
Mistaken as ‘mg’ resulting in overdose |
|
Q.D. |
Latin abbreviation for everyday |
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 |
|
Q.O.D |
Latin abbreviation for every other day |
Misinterpreted as ‘QD’(daily) or ‘QID’.
If poorly written, it looks like ‘I’ |
|
SC / SQ |
subcutaneous |
Mistaken as ‘SL’ (sublingual) if poorly
written |
|
TIW |
Three times a week |
Misinterpreted as three ‘times a day or
‘twice a week’ |
|
D/C |
Discharge or discontinue |
The patient’s medications have been
prematurely discontinued when D/C, (intended to mean ‘discharge’) was
misinterpreted as ‘discontinue’ |
|
CC |
Cubic centimeters |
Mistaken as “U” (units) if poorly
written |
|
HS |
Half strength |
Mistaken as the Latin abbreviation “HS” (half
sleep) |
|
IU |
International unit |
Mistaken as “IV” or “10” |
How to reduce medication errors?
ü Verify every order
ü Use barcodes
ü Be aware of LOOK-ALIKE SOUND-ALIKE (LASA) drugs
ü properly check the prescriptions
ü Design effective warning systems
ü Involve the patient
ü Be proactive
Conclusion
Medication
errors result from poor prescribing, dispensing, or administration of drugs.
The HCP needs to double-check the prescription while dispensing look-alike and
sound-alike drugs which mostly creates confusion. The
important thing is to do after detecting medication error is to correct & make
a report about it
References
Ø https://www.nccmerp.org/about-medication-errors
Ø https://apps.who.int/iris/rest/bitstreams/1070139/retrieve
Ø https://www.drugtopics.com/view/10-strategies-reduce-medication-errors
Written by:
Hyndavi Rajput, Akshaya D
Pharm. D
136/0722
Email:
hyndavirajput@gmail.com
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