Medication Errors (2000) PDF

62 Medication Errors ROBERT CISNEROS I. MEDICATION ERROR PROBLEM A. The 2000 Institute of Medicine (IOM) report To Err Is Human brought the problem of errors in ­medicine to national attention....

62 Medication Errors ROBERT CISNEROS I. MEDICATION ERROR PROBLEM A. The 2000 Institute of Medicine (IOM) report To Err Is Human brought the problem of errors in ­medicine to national attention.1 1. An estimated 44,000 to 98,000 deaths per year are caused by medical errors. Of those deaths, ­approximately 7000 are the result of medication errors. 2. A call to action was given to improve patient safety. B. In recent years, tragic medication errors have focused attention on concerns regarding patient safety. 1. A chemotherapy mix-up at a major cancer center resulted in the death of a patient from a four- fold overdose daily for 4 days. 2. A child accidentally received an intravenous rather than intramuscular dose of long-acting penicillin and died. 3. A compounding error resulted in death of a child who received a tricyclic antidepressant at a dose 10 times greater than the dose prescribed by physician. 4. Mix-ups with heparin vials that had similar packaging, but different concentrations, resulted in overdoses causing serious injury and several infant deaths. II. ERROR DEFINITION. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines a medication error as follows: “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 the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”2 III. TYPES OF ERRORS. The following categories of errors have been used in numerous research studies.3 A. Wrong drug error. A drug that was not ordered for a patient was administered—for example, a patient accidentally received furosemide 40 mg orally. Possible causes: The pharmacist accidentally filled the patient’s prescription for an antibiotic with furosemide; the pharmacist reached for the wrong bottle on the shelf and did not check the label carefully enough. B. Extra dose error. A patient receives more doses of a drug than were ordered—for example, a patient was supposed to receive a medication with breakfast for 3 days but received it for 5 days. Possible cause: The patient’s nurse was confused by the medication directions. C. Omission error. A dose of a drug was not administered as ordered but was skipped—for example, a patient was supposed to receive digoxin 0.25 mg orally in the morning but did not receive the dose. Possible cause: The patient’s nurse was so busy that he or she forgot to administer the dose. 1 Kohn LT, Corrigan JM, Donaldson MDS, et al., eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 2 NCCMERP, “What Is a Medication Error,” available at http://www.nccmerp.org/aboutMedErrors.html. 3 Cohen MR, ed. Medication Errors. Washington, DC: American Pharmaceutical Association; 1999. 1196  Medication Errors 1197 D. Wrong dose or wrong strength error. Either the wrong dose of a medicine or the wrong strength is ad- ministered—for example, the patient was supposed to receive warfarin 0.5 mg but received warfarin 5 mg instead. Possible causes: The pharmacist misread the label; the physician wrote the order as “warfarin.5 mg.” Another example: A patient was supposed to receive timolol 0.25% but was given timolol 0.5%. Possible cause: The pharmacist took the wrong product off the shelf, confused by the concentrations. E. Wrong route error. A patient receives a dose of a medication by a route that was not ordered by the physician—for example, a patient was supposed to receive prochlorperazine 10 mg intramuscularly but the drug was administered intravenously. Possible causes: The nurse misread the orders; the phy- sician mistakenly wrote “IV” instead of “IM.” F. Wrong time error. A patient does not receive a dose of medication at the time at which it was to be administered—for example, a hospitalized patient with diabetes is scheduled to receive a dose of insulin immediately before breakfast (at 7:00 a.m.), but the dose is given 2 hrs after breakfast. Possible cause: The nurse was busy and could not give dose on time. G. Wrong dosage form error. A patient receives a dose of medicine in a dosage form that was not ­intended—for example, nicotinic acid 500 mg tablets were ordered for a patient who instead receives nicotinic acid 500 mg slow-release capsules. Possible cause: The pharmacist did not carefully check the product or was confused by the label. H. Other. Errors that do not fit into any of the other categories. IV. COMMON ERROR HAZARDS A. Dangerous abbreviations. Numerous common abbreviations and symbols have been associated with errors. Detailed lists are available from the Institute for Safe Medication Practices (ISMP) at http://www.ismp.org/tools/errorproneabbreviations.pdf and The Joint Commission at http://www.jointcommission.org/assets/1/18/official_do_not_use_list_6_111.pdf. JCAHO’s accredited organi- zations are required to avoid using the potentially confusing abbreviations on its “do not use” list. 1. U, IU: unit(s). The letter U can easily be misinterpreted as a number (e.g., 0 or 4), and serious harm has occurred with insulin and heparin as a result of this confusion. For example, a patient received 66 units of insulin instead of 6 units. The order, which was written for “6U” of regular insulin, was misread as 66. The word units should be written out in full. 2. QD, Q.D., qd, q.d. (daily). These common abbreviations have been misinterpreted as “QID” or “qid” (four times daily) resulting in overdoses. The word daily should be written out in full. 3. Q.O.D, QOD, qod (every other day). These common abbreviations have been misinterpreted as QID (four times daily), resulting in overdoses. The words every other day should be written out completely. 4. Trailing zero. When a dose is ordered and followed with a decimal point and a zero, such as 2.0 mg or 25.0 mg, errors can occur. The decimal point may be missed and an overdose can occur. For example, warfarin 2.0 mg may be misinterpreted as 20 mg. Trailing zeros should be avoided, and the dose written without the additional zero—for example, warfarin 2 mg (instead of 2.0 mg). 5. Lack of leading zero. A drug’s dose may be less than 1 mg, such as for digoxin. Often the dose is written without a leading zero: digoxin.25 mg instead of digoxin 0.25 mg. Errors have occurred ­because the decimal point is missed—for example, warfarin.5 mg may be interpreted as warfarin 5 mg. ­Leading zeroes should be included, so the dose is written as digoxin 0.25 mg or warfarin 0.5mg. 6. MS, MSO4 (morphine sulfate), MgSO4 (magnesium sulfate). The abbreviations for morphine sulfate and magnesium sulfate are quite similar and can be confused. It is recommended that morphine sulfate and magnesium sulfate be written out in full. B. Other confusing symbols and abbreviations. There are numerous other hazardous symbols and abbreviations that should be used with caution when writing prescription orders and carefully exam- ined when filling prescriptions. Examples include the following: 1. cc. Stands for cubic centimeters and is often used instead of mL. This has been misinterpreted as a 0 (zero); use mL. 2. mg. Used for micrograms—for example, levothyroxine 250 mg daily. The abbreviation has been mis- taken for mg, and overdoses have occurred; better to use mcg or to write out the word ­micrograms. 3. ,,.. Symbols for less than (,) and greater than (.) have been mistaken for each other or ­misinterpreted as numbers. Better to write out the words less than or greater than. 1198 Chapter 62      IV. B 4. HCT. This abbreviation for “hydrocortisone” has been misinterpreted as hydrochlorothiazide. Better to write out the word completely. 5. HCl. The abbreviation for “hydrochloric acid” has been misinterpreted as KCl (potassium ­chloride). Better to write out the words completely. C. Sound-a-like or look-a-like drug names. The ISMP has a list of confusing drug names available at http://www.ismp.org/Tools/confuseddrugnames.pdf. 1. Examples include the following: a. Amitriptyline and aminophylline b. Cisplatin and carboplatin c. K-Dur and Cardura 2. To avoid these problems, the ISMP offers several suggestions, including the use of computerized reminders, name alert stickers, and independent checks; opening the bottle in front of the patient, who can confirm the appearance; and reporting errors. D. High-risk drugs. Certain potent drugs have been implicated in many serious and tragic medication errors. These have been called high-risk or high-alert drugs. A list of such medications can be found at http://www.ismp.org/Tools/highalertmedications.pdf. Examples include the following: 1. Blood-modifying agents such as heparin and warfarin. Errors have resulted in serious injury or death from hemorrhaging as a result of overdose (patient receiving 10 mg instead of 1 mg) or from blood clots as a result of underdose (patient receiving 0.5 mg instead of 5 mg). 2. Narcotics and sedatives. Central nervous system depression and respiratory arrest have resulted from errors with these drugs, such as diazepam 25 mg given intravenously instead of 2.5 mg. 3. Neuromuscular paralyzing agents such as succinylcholine and vecuronium. Accidental use or inadvertent use before adequate ventilation procedures were started has resulted in respiratory arrest and death. 4. Chemotherapy drugs. These drugs are associated with potent adverse effects, affecting numer- ous body systems, such as the immune, neurologic, and clotting systems. Deaths have occurred as a result of errors with these products. For example, vincristine was accidentally given to a child ­instead of vinblastine, resulting in death. Confusion over the dosing of cyclophosphamide resulted in a fatal fourfold overdose. V. SEVERAL SAFETY TECHNIQUES OBSERVED IN COMMUNITY PHARMACIES4 A. Keep work procedures organized and simplified. B. Do not work on several prescriptions at once, just one at a time. C. Manage interruptions, do not be pressured to rush. D. Smell check. E. Bar code check. F. Use a magnifying glass when needed. G. Enhance the design of the facility. VI. ROOT CAUSE ANALYSIS (RCA). This is a structured process for identifying direct and indirect factors that contributed to a medication error. The Joint Commission presents a “Framework for Conducting an RCA and Action Plan” that can be downloaded at http://www.jointcommission.org/ Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/. A. Important questions to ask: 1. What happened and why? 2. What were the contributing factors? a. Age? Hours worked? Staffing? b. Workload? Stress? Confusing names? Location on shelf? c. Inadequate information? Communication? d. Inadequate equipment? 4 Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc. 2003;43(2):191–200.  Medication Errors 1199 e. Workplace atmosphere conducive to safety? f. Inadequate training of pharmacist or technician? B. Latent defect. A weakness in a system that does not immediately result in an error but, under the right set of circumstances, can contribute to a mistake. For example: 1. Stocking look-alike or sound-alike drugs next to each other, contributing to a pharmacist incor- rectly filling a prescription 2. Inadequate training of employees, contributing to an error in which an automated dispensing machine was used improperly and a patient received the wrong medication VII. NATIONAL SAFETY EFFORTS A. The Joint Commission’s current National Patient Safety Goals for Accredited Organizations can be found at http://www.jointcommission.org/mobile/standards_information/national_patient_safety _goals.aspx. Hospital goals include: 1. Improve the accuracy of patient identification. Have two means of identifying the patient other than room number. 2. Improve communication among caregivers. Verify and read back telephone and oral orders. 3. Create a list of “do not use” abbreviations. Standardize the abbreviations used, and prohibit the use of those that are prone to confusion and misinterpretation. 4. Improve the safe use of medicines. a. Limit the number of different concentrations available per drug product; standardize. b. Develop methods of identifying and reviewing sound-alike and look-alike drugs, preventing errors with them. c. All medications and containers should be properly labeled. d. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. 5. Reduce the risk of infections. a. Comply with all Centers for Disease Control and Prevention (CDC) recommendations for hand washing and hygiene. b. Thoroughly investigate all serious adverse events and deaths associated with infection acquired in a health care setting. 6. Keep accurate patient medication records and histories throughout the continuum of care. a. Ensure that a patient’s medication records are complete and accurate when he or she is referred or transferred within or between organizations. b. Proper communication of accurate patient medication information is critical for everyone involved in the patient’s care. B. The 5 Million Lives Campaign initiated by the Institute for Healthcare Improvement can be found at http://www.ihi.org/IHI/Programs/Campaign. 1. Purpose: “To protect patients from five million incidents of medical harm over the next two years (December, 2006 to December, 2008).” 2. Twelve interventions were identified and can be found described in more detail at the aforemen- tioned Web site. The interventions included: a. Preventing adverse drug events through medication reconciliation b. Preventing surgical site infections by appropriate care and antibiotic use c. Focusing on preventing harm from high-risk medications such as anticoagulants, sedatives, narcotics, and insulin d. Reducing methicillin-resistant Staphylococcus aureus (MSRA) infections through appro- priate evidence-based practices C. The IOM in July 2006 released its report “Preventing Medication Errors.” Several recommendations were made to improve patient safety including enhancing role of patient in medication ­management, improving patient education, and increasing the use of technology, such as e-prescribing. This report can be accessed at http://www.iom.edu by searching for “Preventing Medication Errors.” D. Medication error reporting. The reporting of medication errors provides critical safety feedback. The ISMP Medication Error Reporting Program (MERP) provides an online, confidential means of error reporting. According to the ISMP, the inclusion of the reporter’s identity and location is ­optional. The information is shared with the FDA’s MedWatch program as well as with the ­manufacturer/labeler. The Web site is located at https://www.ismp.org/orderforms/­reporterrortoismp.asp. 1200 Chapter 62      VII. E E. The Sorry Works Coalition (http://www.sorryworks.net) is an organization of various individuals (health care professionals, lawyers, insurance executives, concerned citizens, etc.) who promote the necessity of disclosure and apology following error. The coalition provides training and education programs. F. The Institute for Safe Medication Practices (http://www.ismp.org) focuses its efforts on medication error prevention and patient safety. The ISMP publishes four different safety newsletters, provides consulting services, and presents numerous educational programs, services, safety recommendations, and activities. G. The National Patient Safety Foundation (http://www.npsf.org) represents stakeholders from a broad array of disciplines, including patients and families. The NPSF mission is focused on improving patient safety. It provides numerous resources, publications, and activities directed at improving the care of patients. H. The Institute for Healthcare Improvement (IHI) has created the IHI “Open School” at http://www.ihi.org/offerings/IHIOpenSchool/Pages/default.aspx. Online modules regarding patient safety and quality assurance are available. Additional resources and material are provided. Student chapters of the Open School exist and information is provided on how to initiate these chapters. Study Questions Directions: Each of the questions, statements, or 4. A hospital pharmacy begins stocking new intravenous incomplete statements can be correctly answered or mini-bags of a neuromuscular-blocking agent. The completed by one of the suggested answers or phrases. packaging is similar to a commonly used intravenous Choose the best answer. antibiotic. The addition of the new mini-bags was not widely communicated to all personnel. One weekend, 1. A major result in the 2000 Institute of Medicine several doses of this new product were accidentally (IOM) report is that dispensed in place of the intended doses of antibiotic. (A) pharmacists are not blamed for most medical Several patients suffered respiratory arrest and one of errors. the patients eventually died. What would a root cause (B) surgeons make more mistakes than any other analysis of this error find? health professional. (A) The only cause of this error was a pharmacist who (C) pharmacists make more mistakes than any other was not paying attention. The pharmacist should health professional. be dismissed. (D) there is now more emphasis on error prevention. (B) Poor communication practices is a latent defect 2. A pharmacist is presented a prescription for 250 mcg in this pharmacy system and significantly of levothyroxine. Which of the following dosages contributed to the error. would be equivalent to that amount? (C) The pharmacy technicians are to blame for this (A) 2.5 mg error, not the pharmacist, because the technicians (B) 0.25 g obtained the mini-bags from stock and placed the (C) 0.25 mg labels on the bags. The pharmacist checked only (D) 25 g the technician’s work. The technician should be dismissed. 3. A prescription is written for warfarin 1.0 mg. (D) This is an example of an extra dose error. The community pharmacist accidentally dispenses 10 mg. The patient develops severe bleeding within 3 days and nearly dies. Which of the following is the most accurate assessment of this prescription? (A) A trailing zero is present in this prescription and could have contributed to the pharmacist’s error. (B) This is an example of a leading zero, which contributed to the error and the patient tragedy. (C) Sound-alike medications contributed to this error. (D) This does not qualify as an error based on the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) definition.  Medication Errors 1201 5. What do the following abbreviations MS, MSO4, 6. A major error in a hospital pharmacy resulted in a and MgSO4 have in common? total parenteral nutrition solution being mistaken for (A) Common abbreviations for morphine sulfate a cardioplegic solution for coronary bypass surgery. (B) Common abbreviations for magnesium sulfate Which of the following is true regarding the root cause (C) Should not be used in the Joint Commission– analysis that was done at the hospital after the error? accredited institutions (A) The primary objective is to find out which (D) Approved abbreviations in most hospitals pharmacist made the mistake that allowed this to take place. (B) The result of the analysis would be the admission that an error had taken place. (C) All factors that could have contributed to this error would be identified and analyzed. (D) A root cause analysis would be inappropriate in this case. Answers and Explanations 1. The correct answer is D [see I.A.2]. the technician and pharmacist totally from any blame The IOM report revealed alarming data on deaths but emphasizes the significant role that failure of com- ­related to medical errors. The report contributed to munication played within this pharmacy system. The ­increased efforts to improve patient safety. ­system was as much or more to blame than any in- dividuals. Firing the individuals does not repair the 2. The correct answer is C [see III.D]. problem of poor communication in the system but Although this may seem to be an elementary ques- only sets the stage for a similar mistake to occur again. tion and answer, a wrong dose error such as this could ­easily lead to a serious injury or death to a patient. 5. The correct answer is C [see IV.A.6]. These abbreviations are included in the Joint Com- 3. The correct answer is A [see IV.A.4]. mission’s “do not use” list. Errors resulting in serious Warfarin 1.0 mg is an example of a trailing zero. The harm have occurred after mix-ups with morphine and Joint Commission has included this in its “do not use” ­magnesium. list of abbreviations. However, in the community ­setting, it is a practice that can still be frequently seen on pre- 6. The correct answer is C [see VI.A.2]. scriptions. When a trailing zero is observed, much cau- A root cause analysis is not intended to focus on blame tion should be exercised in interpreting the prescription. but on all factors that could have been related to this ­error. Factors might have included training of phar- 4. The correct answer is B [see VI.A.2]. macist and technicians, the actual drug order, and Poor communication was a major contributing factor the label. The contribution of such factors might not to this tragic series of errors. The drug was a high-risk be discovered if the focus is on only identifying which drug and had similar packaging as another commonly pharmacist, technician, or other professional is to used drug. These are two major ingredients for the blame. ­serious error that took place. This does not absolve