Medication Errors & Classifications

• Emily Jerry, diagnosed with a yolk sac tumor at 18 months, died after a pharmacy technician used a 23.4% sodium chloride solution instead of the standard 0.9% saline solution during her chemo session.
• This was classified as a Category A medication error.

Definition of a Medication Error

• A medication error is any preventable event that may cause inappropriate medication use or patient harm while the medication is under the control of healthcare professionals, patients, or consumers.
• Key aspects include preventability, the potential for harm, and the scope of responsibility.

Categorization of Medication Errors

• Category A: Circumstances or events with the capacity to cause error.
• Category B: An error occurred, but no harm resulted.
• Yellow: Errors may cause harm, requiring intervention.
• Green: Death is caused by an error.

Adverse Drug Reaction vs. Adverse Drug Event

• Adverse Drug Reaction (Reaction): A noxious and unintended response to a drug at normal doses. Example: GI distress from an antibiotic.
• Adverse Drug Event (Event): Harm experienced by a patient due to medication exposure, not always caused by errors.
• Medication Error encompasses Adverse Drug Event, which encompasses Adverse Drug Reaction.

Types of Adverse Drug Events

• Preventable: A medication error reaches the patient and causes harm. Example: Wrong patient receives lisinopril, experiences low blood pressure, leading to dizziness and a fall.
• Potential: An event that does not reach the patient. Example: Lisinopril is sent to the pharmacy for the wrong patient, but the error is caught before the patient takes it.
• Ameliorable: Not completely preventable but could have been mitigated. Example: A patient prescribed furosemide presents to the ED with dehydration because of a lack of early follow up after 10 days as opposed to a previously scheduled 2 months.
• Non-Preventable (ADR): An adverse drug reaction occurs despite correct procedures. Example: A baby with no known allergies develops a rash from amoxicillin due to an unforeseen penicillin allergy.

Medical Errors vs. Medication Errors

• Medical errors are estimated to be the third leading cause of death in the U.S., accounting for approximately 250,000 deaths annually.
• Medication errors are a subset of medical errors.

Statistics of Adverse Drug Events

• Adverse drug events account for 700,000 ER visits and 100,000 hospitalizations annually.
• Close to 5% of hospitalized patients are affected by adverse drug events.

Risk Factors for Adverse Drug Events

• Polypharmacy: Taking five or more medications increases the risk of drug interactions and side effects.
• Health Literacy: The ability to use health information to make informed decisions. Lack of health literacy can lead to misreporting of allergies or incorrect medication use.
• Age: Older adults and children are at higher risk due to body composition and the likelihood of being on multiple medications.

Economic Impact

• The average cost of each preventable ADE is approximately $4,600-$4,700.
• One university hospital reported spending $1.5 million annually on medication-related problems.

Medications Commonly Associated with ED Visits

• Four medications account for over 50% of ED visits.
  • Insulin: Can cause blood sugars to drop too low.
  • Antiplatelet and Oral Anticoagulants: Can cause bleeding.
  • Opioids: Can cause overdose.

Medication Stages and Pharmacist Role

• The pharmacist plays a crucial role in transcribing, dispensing, administration (e.g., vaccines), and prescribing/ordering (in collaborative practice settings).

Types of Medication Errors

• Omission: Something is missing.
• Wrong Drug
• Wrong Dose: The quantity of medication given is incorrect.
• Wrong Patient
• Wrong Technique
• Prescribing Error
• Wrong Route: Medication is administered via an incorrect route.
• Wrong Time: Medication is given at the wrong time.
• Wrong Dosage Form

The "Rights" of Medication Administration

• Right Drug
• Right Dose
• Right Route
• Right Time
• Right Patient

The Swiss Cheese Model

• The Swiss cheese model illustrates how errors can occur when multiple layers of defense fail.
• Latent Factors: Accidents waiting to happen, such as poorly designed equipment or inadequate training.
• Error-Producing Factors: Environmental factors, such as workspace conditions and distractions.
• Active Failures: Human errors or violations of protocol.
• Defenses: Systems in place to catch errors, such as tech-check-tech systems and pharmacist verification.

Role of the Pharmacist

• The pharmacist serves as the last check in the medication process.
• Ideally, the pharmacist catches errors before they reach the patient.
• The patient is also a critical last check.

Pharmacy Workflow

• The typical pharmacy workflow consists of five sections:
  • Patient Drop Off
  • Data Entry
  • Dispensing (labeling and packaging)
  • Verification
  • Pick Up
• Errors can occur at any of these stages.

Error Prevention Strategies by Workflow Stage

• Drop-Off: Use double identifiers, thoroughly review clinical information (allergies, medications, indications, past medical history, pregnancy status, weight), and be cautious of same-household patients, common names, and similar addresses.
• Data Entry: Write legibly, use the read-back method for voicemails, clarify ambiguous directions, and avoid error-prone abbreviations.
• Dispensing: Check for correct strength and formulation, be aware of look-alike/sound-alike medications, use barcode scanning, and avoid swapping labels.
• Verification: Avoid computer/alert fatigue, take time to focus, double-check even with experience, and ensure patient education.
• Pick-Up: Use two patient identifiers, dispense measuring devices with liquids, provide patient education, and alert patients to manufacturer changes.

Common Errors and How to Avoid Them

• Error-Prone Abbreviations: Avoid abbreviations like "QD," "QOD," "cc," and "U." Write out "daily," "every other day," "mL," and "units".
• Trailing and Naked Decimal Points: Always use a leading zero for decimal values less than one (e.g., 0.5 mg) and avoid trailing zeros (e.g., 1 mg instead of 1.0 mg).
• Incorrect Strength: Check the patient's profile, but verify with the prescriber, especially for medications like warfarin where doses can change.
• Wrong Formulation: Pay close attention to the formulation, especially when selecting from a dropdown menu. Verify with the prescriber if there is any doubt.
• Look-Alike/Sound-Alike (LASA): Use tall man lettering, separate LASA drugs on the shelf, and double-check the medication before dispensing.
• Oral Solutions: Clarify whether the dose is in milliliters or milligrams, dispense with a measuring device, and provide clear instructions to the patient.
• Computer/Alert Fatigue: Pay attention to alerts, even if they seem repetitive. Take breaks to avoid fatigue and refocus if interrupted.
• Lack of Patient Knowledge: Provide thorough patient education, including demonstration of proper technique for devices like inhalers and insulin pens. Ask open-ended questions to assess patient understanding.

Avoiding Errors: Rx Drop-Off

• Update records routinely to include new diagnoses.
• Always update allergy information.
• Deactivate old prescriptions to avoid alert fatigue.
• Ask about the clinical purpose or indication of the prescription if there are any questions.

Avoiding Errors: Order Entry

• Use the read-back method for verbal prescriptions.
• Have a second person listen to voicemails.
• Clarify illegible prescriptions.
• Document who you spoke with, the date, the time, and what they told you when calling a doctor's office.

Avoiding Errors: Dispensing

• Ensure it is the right medication.
• Organize stock to separate commonly confused drugs.
• Utilize shelf dividers and stock alphabetically.
• Use barcode scanning and do not override without verifying.
• Use baskets for individual patients.

Avoiding Errors: Drug Utilization Review (DUR)

• Use DUR popups to ensure the appropriateness of dispensing two things together.

Avoiding Errors: Verification

• Avoid confirmation bias by systematically verifying each aspect of the prescription.
• Pay attention to alerts.

Avoiding Errors: Rx Pick Up

• Use two patient identifiers communicated by the patient.
• Dispense measuring devices with liquids.
• Provide patient education, including show and tell for devices.
• Alert the patient if there is a manufacturer change.
• Empower patients by informing them about their drugs (names, strengths, dosing, side effects).
• Ask open-ended questions to gauge patient understanding.