Medication SafetyA medication error is a drug error that may

or may not reach the patientIt is usually preventableIt is usually unintentionalMay or May not cause harm

A medication error that causes death is called a sentinel event by the Joint Commission

When a sentinel event occurs the institution is required to perform a root cause analysis

Type of Medication Errors Prescribing Errors

Involves wrong dose, illegible sigs, wrong frequencies Incorrectly transcribing verbal orders from MD

Dispensing Errors Results from mistakes made during dispensing Physically preparing medications incorrectly (i.e. using 23.4% saline

instead 0.9% saline for an IV admixture) Transcribing sig instructions incorrectly

i.e. Methothexate 12.5 mg tablet TIW as 12.5 mg TID Error in dosing calculations

Administration Errors Involves nursing Incorrect route of administration

Giving KCL 40 meq IVP instead of KCL 40 meq IVPB over 60 minutes (FATAL) Giving Vincristine intrathecally instead of intravenously (Fatal) Giving Penicillin G Benzathine IV instead of IM (can be fatal)

Causes of Medication ErrorsPerformance problemsProcedure(s) not followedKnowledge deficitsPharmacists/Pharmacy Technicians that may

be intoxicated by alcohol or drugsSocial or Family problemsNoise level at workDistractions

Medication Error Reduction StrategiesJoint Commission “Do not use” listISMP (Institute for Safe Medication

Practices) error prone do not use listSee Lesson 3 “Medical and Pharmacy

Terminology”Also see

www.ismp.org/tools/errorproneabbreviations.pdf

ISMP also publishes a list of confused drug names Example concludes Celebrex-Celexa List can be found at

www.ismp.org/tools/confuseddrugnames.pdf

Tall Man Lettering Tall Man lettering is a strategy implemented by healthcare

institutions in the US under the advise of the Joint Commission , FDA and ISMP

Involves drug names that can be confused with one and other, see ISMP confused name’s list

Drugs with similar sounding names or spelling are called LASA drugs-Look Alike Sound Alike drugs

Tall man lettering involves the use of mixed case lettering to distinguish between these drugs

Examples: buPROPion VS busPIRone glyBURide VS glipiZIDE hydrALAZINE VS hydrOXYzine

Tall man strategies involves: labeling of these medications, ADC cabinet display, separating these drugs on pharmacy shelves

High Alert MedicationsMedications that when used in error can result

in serious patient harm including deathISMP has collected a list of such drugs

Category Examples

Concentrated electrolytes

KCL 2 meq/ml, Calcium chloride 10% , 3% saline, 23.4% saline

Narcotic Opiates Morphine, Hydromorphone

Anticoagulants Heparin, Warfarin

NMB Succinylcholine, Rocuronium

Hypoglycemics Insulin, oral drugs (glipizide)

Chemotherapy Drugs Methothexate, Doxorubicin

High Alert Medication StrategiesUS hospitals and healthcare institutions have

published their own lists that mirrors the ISMP list with some additions.

Strategies include: Specialized color code labeling for these medications Segregating the medications in the pharmacy inventory Restricting access to these drugs in the ADC (non

overrideable) Specialized alerts in the CPOE and the pharmacy

systems Use of standardized preparations of these drugs

i.e. Heparin USP 25,000 units/250 ml D5W

Do Not Crush List ISMP publishes a do not crush list These drugs should never be crushed Typically patients that can’t swallow or have feeding tubes, NG tubes and

PEG tubes have their oral dose forms crushed and administer in about 30 ml of liquid

Crushing some drugs alters their time course of activity, stability, or expose potential harm to pharmacy personnel Drugs that are long acting

Effexor XR, Cardizem CD, Detrol LA, KDUR, Paxil CR, Seroquel XR Drugs that are enteric coated

Ecotrin Depakote Nexium

Powerful GI irritant Actonel®

Teratogenic (exposure to female pharmacy personnel) Isotretinoin

Sublingual Dose Forms Nitroglycerin

www.ismp.org/Tools/donotcrush.pdf

Medication ReconciliationMedication Reconciliation (MedRecon)

Required by Joint Commission in accredited healthcare institutionsDesigned to help prevent medication errors due to duplications,

drug interactions and omissionsThe process of medication review that is driven by the prescriber

primarily During Triage in the ER, a primary list of medications, OTC and herbals

that patient is taking is to be generated (along with doses and indications) along with admission orders

During each transition of care (i.e. ER to inpatient unit, inpatient unit to critical care (ICU)) a review of this list is mandatory along with current inpatient medication list. Based on this, meds should be discontinued, maintained or changed with Transfer orders

Upon Discharge, the primary list is reviewed and a discharge medication list given to the patient explaining any changes to the patient. Discharge medication list is also to be provide to the patient’s primary care provider to update the patient’s care

How to report med errors and adverse drug eventsFDA MedwatchISMP MERP databaseInstitute of Medicine (IOM)TJC (Joint commission)USP MedmarxFDA and CDC VAERS system for vaccinesFAERS is a database that contains

information on med errors and adverse reaction

Pharmacy Technician Role in Error PreventionQuestion illegible handwriting on written

prescriptionsAlways keep Rx and labeling in mind when

filling RxCarefully key in data in pharmacy systemAsk patient about OTC and herbal

medications

Handling of Hazardous DrugsOSHA establishes ruleHazardous Materials are defined according to their

corrosivity, toxicity, ignitability and chemical reactivityEstablishes four class of such material. Pharmacy is

concerned with U and P listed chemicalsU and P must be in containers clearly labeled as such

Examples of P listed drugs: warfarin, nicotine, nitroglycerin, physostigmine

Examples of U listed drugs: mercury, chloral hydrate, chlorambucil, lindane, phenol, mitomycin, most chemo agents

Vendors remove these chemicals from the pharmacy