Medication Order Process

Medication Safety Errors

• Pharmacovigilance involves looking at every step of the medication process

Case Studies

• A 9-month-old infant died after receiving ten times the prescribed morphine dose due to a misplaced decimal point; a doctor prescribed 0.5 milligrams of morphine, but the infant received 5 milligrams
• A 60-year-old woman and an 83-year-old woman received fatal doses of beta-blocker and morphine respectively, both ten times the prescribed amount
• Decimal points are very important

Medication Order Process

• Drug procurement errors can lead to medication errors, such as when a supplier provides fewer boxes than needed and medications are bought online as replacements, leading to failure of treatment
• Pharmacy storage errors, such as deviations from the manufacturer's specified storage conditions, can cause problems
• Starts with a prescriber writing an order
• Followed by a nurse or clerk taking the order off the chart
• The order is transported to pharmacy
• A pharmacist reads the order
• The pharmacist prepares the order for delivery
• Transportation of drugs to nursing unit
• Ordered drugs are placed in patient meds receptacle
• Delivery of drugs to the patient’s room for administration
• Patient identification verification
• Medication administration to the patient
• Documentation of administration by the nurse
• Pharmacists significantly contribute to resolving medication order problems in this process
• Computerized Prescribing Order Entry simplifies the process and reduces potential errors

Health Professionals

• Multiple health professionals are involved in medication use

Costs

• Incorrect medication use results in significant annual costs in the US due to hospitalizations

Key Definitions

• Medication error: A preventable event from improper medication use that can cause harm
• Medication misadventure: Any event associated with medication administration resulting in an unexpected or undesirable outcome
• Adverse drug event: Patient injury resulting from medication use
• Adverse drug reaction: Unexpected, unintended, undesired, or excessive response to a medication
• Determining the ADE and its cause is important, but sometimes the issue lies with the patient and not the drug itself

NCC MERP Index

• There is importance in identification of Adverse Drug Event (ADE) and cause

JCAHO Root Causes of Medication Errors

• Joint Commission on Accreditation of Healthcare Organizations (JCAHO) identifies lack of training, communication, and standardization as root causes
• Training is crucial as a lack of personnel training can lead to mistakes
• Communication errors can occur during information transmission between health professionals, emphasizing the importance of mindfulness
• Standardization requires the use and adherence to Standard Operating Procedures (SOPs) and guidelines

Common Causes

• Poor penmanship and unfamiliar abbreviations were historical factors
• Advances in technology have expanded potential causes to include product labeling/packaging, nomenclature, compounding, and order communication
• Quality control of compounded products must be done by a different person than the one preparing them
• Failed communication and poor drug distribution practices are potential causes of medication errors
• Complex or poorly designed technology can be a risk
• Access to drugs by non-pharmacy personnel
  • Access to medicines should be restricted to authorized personnel only.
• Workplace environmental problems leading to increased job stress
• Dose miscalculations
  • Pharmacists should be present in the wards to recheck nurses' calculations
  • Integration of pharmacists in the SOPs [in the wards/medication administration] is important to avoid issues with the nurses
• Lack of patient information
  • Clinical pharmacists should check patients’ medical records and laboratory tests to check for possible issues such as kidney or liver problems, and compute the correct dose specified for it if there are any issues
• Lack of patients' understanding of their therapy

Failed Communication

• Handwriting, oral communications, wrong/incomplete transcription, and illegible handwriting can cause errors
• Dosage strength, dosage form, frequency, route of administration, time of intake, duration of intake
• Sound-alike and look-alike drugs can cause errors
• Missing or misplaced zeroes and decimal points can cause errors
• Confusion between metric and apothecary systems of measurement can cause errors
• Use of nonstandard abbreviations, ambiguous or incomplete orders can cause errors
• A written prescription should be provided within 24 hours of a verbal order
  • Telephone calls are not considered official prescriptions since they are prone to errors
• Each health institution has its own set of approved abbreviations
• Institute for Safe Medication Practices (ISMP) has a list of error-prone abbreviations, symbols, and dose designations (https://shorturl.at/BOq3J)
• Some ISMP abbreviations can be mistaken for other terms
  • Use complete drug name

Poor Drug Distribution Practices

• No counter checking of written order from prescription to transcription to dispensing to delivery to administration can cause errors
• Several checkpoints that can be considered during dispensing
  • when receiving the prescription
  • taking the medication from the shelf
  • when the medication is taken to the patient
• There are also practical tests done to check how fast and accurate the interns dispense.
• No proper arrangement of medicines in either pharmacy or nursing units can cause errors
  • Separate therapeutic categories; include flags or signs for medications with several dosage forms, SALADs
• No facility for storing medicines for each patient can cause errors
  • Watch out for medications that need refrigeration or special storage conditions
• Lack of SOPs for handling medicines in the pharmacy and in the clinical areas
  • SOPs are needed to ensure that mistakes are not repeated
• No monitoring and documentation of medication safety in the hospital

Workplace Problems

• Distractions
• Lack of Personnel
• Workload
• Extended shifts
  • Can reduce mental capacity
• Unclear job descriptions
• Lack of space

Other Causes

• Dose miscalculations
  • Reconstitution medication, measuring
  • Can happen even at home
    • Listen carefully to instructions regarding dosage
• Lack of patient information
  • Read patient medical record (laboratory results, observations), they can help develop a comprehensive idea on patient condition
• Not standardized medical abbreviations or illegible handwriting
  • Such as qd (once a day) can be read as qid (four times a day) or qod (every other day)’
  • Sq (subcutaneous) misinterpreted as sl (sublingual)
  • TIW (three times a week) misinterpreted as three times a day or twice a week
  • dc (discontinue) misinterpreted as discharge
  • HS (half strength) misinterpreted as hour of sleep
  • Cc = 1 ml
• Lack of the patient’s understanding of their therapy

More Medication Errors

• By type
  • Drug omitted, improper dose/quantity, unauthorized drug, prescribing error, wrong time of administration, extra dose, wrong patient, wrong drug preparation, wrong route, wrong administration technique, wrong dosage form
• By reported cause
  • Performance deficit, procedure or protocol not followed, transcription inaccurate or omitted, documentation, computer entry, communication, knowledge deficit, drug distribution system, written order, illegible handwriting or unclear

Medication Order Processing Site

• Drug procurement and pharmacy Storage are not part of the medication use process but they are still sites for possible error
• Medication order processing is a site for errors

Writing Orders

• Avoid using greater than or less than symbols; write drug names in full; avoid apothecary units
• Write "at" instead of using @ symbol, use mL or milliliters instead of cc
• Use mcg or micrograms instead of the symbol micrograms

Challenges

• Need accessible and easy-to-use reporting methods
• CPOE and barcoding, elimination of handwriting discrepancies, immediate error checking for dosage, frequency, and route of administration help resolve challenges
• Drug interaction and allergy checking, drug information databases, tools to document administration of drugs, and immediate transmission of orders to several disciplines help resolve challenges
• In other countries, robots fulfill the order and the pharmacist simply checks before the robot delivers it to the patient
• Other hospitals in Manila use Viber as communication
• Changing attitudes and prejudices
• Training personnel involved in the medication order processing and administration
• There are now many ways to address these problems; it is now up to us to utilize and maximize the technologies that are available to us.