The Pharmacy’s Role in Reducing
and Preventing Medication Errors:
What are the Real World Issues?
Richard B. Greene, PharmD, MBA, FASCP
Vice President of Government Affairs & Pharmacy Relations
Hospice Pharmacia * hp RxOptions
Services of excelleRx
[email protected]
215-282-1674
1Disclaimer
I, Richard B. Greene, do not have any
real or apparent commercial affiliations
related to the content of this
presentation.
2
Objectives
Goal: provide pharmacists and pharmacy technicians with the skills necessary to identify medication errors and to develop methods for reducing the possibility of future errors.
What are the real everyday challenges? * Explain confirmation bias *
Identify Sound-Alike, Look-Alike, Packaging error
challenges *
Define the a non-punitive environment *
* Also applies to pharmacy technicians
3
Medication Errors
“INCOMPETENT PEOPLE ARE, AT
MOST 1% OF THE PROBLEM. THE
OTHER 99% ARE GOOD PEOPLE
TRYING TO DO A GOOD JOB WHO
MAKE VERY SIMPLE MISTAKES
AND IT’S THE PROCESSES THAT
SET THEM UP TO MAKE THESE
MISTAKES.”
4 Dr. Lucien Leape
Harvard School of Public Health
5
Communication issues are a
top contributing factor in
medication-related claims
Drugs more likely to be involved
in serious medication errors
Adrenergic agonists
Adrenergic agonists
Anticoagulants
Anticoagulants
Chemotherapy
Chemotherapy
Chloral hydrate/
Chloral hydrate/
midazolam
midazolam
liquid in
liquid in
children
children
Concentrated
Concentrated
electrolytes
electrolytes
Insulin
Insulin
IV adrenergic
IV adrenergic
antagonists
antagonists
IV
IV
digoxin
digoxin
Neuromuscular
Neuromuscular
blocking agents
blocking agents
Opiates
Opiates
Theophylline
Theophylline
67
Abbreviations
Abbrevs. also cntrbte. to errs., esp. if
they might be interp. diff. by diff. h.c.
provs. E.g., QD has been interp. as
QID when the “.” sep. the Q and D is
carelessly writ. and looks like an “I”.
The ltr. U inst. of the word UNITS may
be interp. as a 0.
Dangerous Abbreviations
“Do not use list”
Abbreviation Intended meaning Common Error Instead Use… IU International units Mistaken as IV, 10 “international unit”
QD, Q.D. Every day “daily”
QOD, Q.O.D. Every other day “every other day”
Trailing zero two milligrams Missed decimal “2 mg”
(2.0 mg) (read as )
Lack leading two-tenths Missed decimal “0.2 mg”
zero (.2 mg) milligrams (read as )
MS, MS04 Confused for one
MgS04 another
8
9
Directions for Use
“The evening before the colonoscopy
procedure, 3 tablets should be taken with 8
ounces of clear liquids every 15 minutes for
a total of 20 tablets. The last dose will be 2
tablets. The day of colonoscopy procedure,
(starting 3-5 hours before the procedure) 3
tablets should be taken with 8 ounces of
clear liquids every 15 minutes for a total of
20 tablets. The last dose will be 2 tablets.”
10
Case
The “Real World”
Dosage errors
Common and preventable dosage mishaps
Incorrect calculations
Incorrect notations
Misinterpretations of the prescribed dose.
Pediatric patients and geriatric patients are
especially susceptible.
13
Written Medication Orders:
Illegible Handwriting
16% of physicians have illegible
handwriting.
1
Common cause of prescribing errors.
2, 3, 4
Delays medication administration.
5
Interrupts workflow.
5
Prevalent and expensive claim in
malpractice cases.
3• 1. Anonymous.JAMA1979; 242: 2429-30; 2. Brodell RT.Arch Fam Med1997; 6: 296-8; 3. Cabral JDT.JAMA1997; 278: 1116-7; 4. ASHP.Am J Hosp Pharm1993; 50: 305-14; 5. Cohen MR.Medication Errors. Causes, Prevention, and Risk Management;8.1-8.23.
Prescription Error Prevention
Legible
Include complete information
Patient-specific information
express weight, volumes, and units using
the metric system
Drug names with caution
Include the medication's purpose
Avoid abbreviations
Avoid decimals
141415
Handwriting
25% of medication errors are the result of
unintelligible orders (Jones, G)
Texas jury blames bad penmanship for
patient death: physician to pay $225,000
Pharmacist cannot escape liability by
hiding behind a physician’s unintelligible
order
The Institute for Safe Medication Practices (ISMP) has called for eliminating handwritten prescriptions.
http://www.ismp.org/msaarticles/whitepaper.html 1616
Prescribing
17
Prescribing
Prescribing and Dispensing
Coumadin or Avandia?
19 20
Oral Orders
Drug orders given orally can be misunderstood, especially if they involve a sound-alike drug, for example:
– Mellaril Elavil – Paxil Taxol – Prilosec Prozac – Cerebyx Celebrex – Oxycontin Oxycodone – Hydroxyzine Hydralazine – Alprostadil Alprazolam
indomethacin: Two 50 mg suppositories verses 250mg suppository
Verbal Orders
Nurse took a verbal order to:
“Increase
LASIX
®to 40 an hour”
However, the prescriber never mentioned
“40 mg per hour,” as was intended
The nurse misunderstood the order as 40 ml
per hour
For nearly 15 hours, the patient received
400 mg of furosemide per hour, a 10-fold
overdose.
21
Case
Verbal Orders
Verbal prescription:
indomethacin
Two 50 mg suppositories
Or
250 mg suppository
22 22Difference Between
“read-back” vs. “repeat-back”
The receiver of the order should write
down the complete order or enter it
into a computer
Then the receiver should read it back
Receive confirmation from the
individual who gave the order
Transcription of Orders
Morphine 0.5 mg
Transcription of Order
The letter U to indicate units
The transcriber thought the order was for 44
units of Humalog® instead of the 4 units it
was supposed to be. The patient only
received one overdose because when
another nurse went to administer the
medication the nurse told the patient the
dose was 44 units of insulin and the patient
said they only took 4 units at home.
25
Case
Transcription of Order
A patient with rheumatoid arthritis came to the
pharmacy wanting to have a prescription for methotrexate filled. The pharmacy technician taking in the prescription asked the patient about allergy information and any other chronic conditions the patient had. The patient provided the
information to the technician. The technician was not familiar with methotrexate and what it was for and how it is typically dosed in rheumatoid arthritis. The prescription was written illegibly. The pharmacy technician typed the prescription as 5 mg once daily. The prescription was actually for 5 mg
once weekly. 26
Case
Transcription of Order
The pharmacy technician could not accurately read
the prescription, but did not question it. If the technician had known that the medication is given once weekly in patients with rheumatoid arthritis this error may have been avoided. It is important for all pharmacy staff to be educated on the drugs they dispense. The better educated they are the less likely an error will occur.
27
Case
Conformation Bias
“IT AIN’T WHAT
YOU KNOW THAT
GETS YOU IN
TROUBLE, IT’S
WHAT YOU
KNOW FOR SURE
THAT AIN’T SO”
–Mark Twain 28
29
31 31
Confirmation Bias
Definition: accept information that
agrees with our hypothesis; Reject
information that does not
Practitioners see the name or dose
that they are most familiar with and
don’t question the order
32
Confirmation Bias
THE PAOMNNEHAL PWEOR OF THE HMUAN
MNID
Aoccdrnig to a rscheearch at Cmabrigde
Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit pclae.
The rset can be a taotl mses and you can sitll raed
it wouthit porbelm.
Tihs is bcuseae the huamn mnid deos not raed
ervey lteter by istlef, but the wrod as a wlohe.
Amzanig huh? 33
Types of “Look-Alike” Names
Handwritten orders
– Some pairs are only confused when handwritten
Beginning of drug name is same
– metFORMIN – metroNIDAZOLE – traMADol – traZADone
Look-alike drug names
– hydRALAZINE & hydrOXYzine – DOPamine & DOBUTamine – morphine & HYDROmorphone – Drug names with and without suffixes
Immediate release and extended release products
34
Sound Alike – Look Alike
I know you believe you understand
what you think I said, but I am not sure
you realize that what you heard is not
what I meant.
(source unknown)
Examples of potential
medication errors
(nomenclature)
The new drug Emend
®(aprepitant) {Chemotherapy-Induced Nausea and Vomiting}sounds like
M-End
®Liquid
(Brompheniramine/Codeine/Phenylephrine), {sinus congestion, runny nose, sneezing, and cough}which is
made in Tennessee and often used in
the surrounding area.
They will sound the same on a called in
prescription.
Look or Sound Alike
Indication for Use
Celebrex – Celexa
Chlorpromazine-Chlorpropamide
Avandia – Coumadin
Lamictal – Lamisil
Isordil – Plendil
Zyprexa - Zyrtec
Arthritis/Antidepressant
Antipsychotic,other/
Diabetes
Diabetes/Anticoagulant
Seizures/Antifungal
CHF/Blood Pressure
Antipsychotic/
Antihistamine
37 38Changes to Brand Names as a
Result of Medication Errors
Losec (confused with Lasix) is now Prilosec Levoxine (confused with Lanoxin) is now Levoxyl Mazicon (confused with Mivacron) is now
Romazicon
Pediaprofen (confused with Pediapred) is now
Children’s Motrin
Altocor (confused with Advocor) is now Altoprev Reminyl (confused with Amaryl) is now Razadyne Omacor (confused with Amicar) is now Lovaza ISMP MSA. July 26, 2007 Volume 12 Issue 15
39
Key concepts in safeguarding
medications
Standardize order communication
Establish and enforce safe ordering guidelines
– list of dangerous abbreviations or dangerous methods of expressing drug information – eliminate use of non-standard symbols
slash mark (/) seen as “1” or “7” Plus sign (+) seen as “4” And signs (&) seen as”2” @ seen as “2”
40
Top 10 Medication Pairs Involved in Wrong
Drug
Errors Reported to PA-PSRS
41 PA-Patient Safety Reporting System Patient Safety Advisory.
Vol. 4, No. 3; September 2007
Morphine oral solutions
Most overdoses occurred when
solution is ordered, dispensed, and
labeled by volume (mL), not dosage
strength (mg)
– Patients received 5 mL of Roxanol
®(morphine) 20 mg/mL (100 mg) instead of
the prescribed 5 mg (0.25mL)
ISMP. (2004).Roxanol involved in another serious error. ISMP
Medication Safety Alert! Community/Ambulatory Edition, 3, 1-2.
Concentrated Morphine
Solution
Two nurses called in sick and the floor had 28 patients
with only one agency (temporary staff) nurse to cover.
Order for Morphine Sulfate 10 mg, the label read,
“Roxanol 20 mg/mL, 10 mg (0.5 mL) po q4h prn”
It was on the MAR between straight orders, not on the prn sheet.
The patient received 200 mg (10 mL) dose instead of 10
mg (0.5 mL) dose and the error was not discovered until 26 hours later.
The nurse charted 20 mL and signed that she gave 20
mL, then actually gave 10 mL.
43
Case
Wrong Drug Errors Involving
Morphine or HYDROmorphone
Of all wrong drug error reports that includemorphine and/or HYDROmorphone, 36% involve a mix-up between those 2 drugs
Of wrong drug reports that involve these 2 drugs
– 62% show morphine as the prescribed medication and HYDROmorphone given in error
– 71% of reports indicate that the errors occurred when these medications were obtained from unit stock Pennsylvania Patient Safety Reporting System. PA PSRS Patient Saf Advis. 2007;4(3):69-108
44
Example of potential
medication errors (packaging)
“I am writing about my concern over 2 look alikelabels for lidocaine. Lidocaine 1% and lidocaine 2% have similar labels. They are both blue and white and both have blue tops. They are both 20 ml. There have been a few instances where these drugs have been stocked incorrectly by pharmacy personnel due to the similar appearance of the labels. I don't know of any instances where patients were harmed, but the potential is definitely there. I suggest that the manufacturer change the color of one of the labels, so there is less chance of a
mix-up.” 45
Case
Pharmaceutical Industry
One of the most frequent causes of
pharmacy medication dispensing
errors is failure to accurately identify
drugs, most prominently due to
look-alike and soundlook-alike drug names.
Leape et al. JAMA 1995; 274:35-43
46
Industry Standards
Develop and enforce
standards for
the design of drug packaging and
labeling that
will maximize safety in
use.
Near Fatal Dose
Dennis Quaid Recounts Twins' Drug Ordeal
Should have received Hep-Lock
(10 units / mL)
Were given Heparin
(10,000 units / mL)
Near Fatal Overdose
Question:
– What was a contributory factor in this medication error? 4949
Similar Packaging
50 50Similar Packaging
51Similar Packaging
52Similar Packaging
53Similar Packaging
54Confusing Packaging
55
Confusion of Products
Physician recommended: Patient took:
56 Active ingredient
Bisacodyl……...laxative
Active ingredient
Docusate sodium………….stool softener
Label Identification
57Fleets Phosopho-Soda
Packaged in
– 1 1/2, 3, & 8 oz Several patients
ingested 8 oz
1 Death
Several Injuries
Result: no longer
manufacturing of 8 oz
58Why Pre-Marketing
Labeling and Packaging
Review?
FDA focus on New
Medications
Vulnerable to confusion
– Names - Nomenclature
– Labeling and packaging
– Dosing
– Route of administration
– Special uses
61
http://www.accessdata.fda.gov/psn
http://www.accessdata.fda.gov/psn
/
/
Practitioners and
Healthcare Systems
Medication errors have much more to
do with breakdown in the system than
with anyone’s competency
62
Systems of Medication Use
Patient Information Drug Information – References – computer systems – Formulary – clinical pharmacists Communication – Dynamics
– order and drug information
Labeling, Packaging
and Nomenclature
Patient Education
Device Acquisition,
Use and Monitoring
Environmental Factors Staff Competency and
Education
Drug Storage, Stock, and Distribution Quality Culture – RM/QI efforts – independent checks – Infection Control 63
Establish Non-punitive
Environment
“Drive out fear” by reducing emphasis
on punishment
ADEs are always opportunities to learn
about the system
Punishment (e.g., sanctions,
embarrassment, remedial education)
drives errors underground where no
one can learn from them, leaving
system unchanged
64Primary Principles in Error
Reduction
Reduce or eliminate the possibility of
errors
Make errors visible
Minimize the consequence of errors
Report and analyze internal errors
Report errors externally
65
Make Errors Visible
Pharmacy IT systems/CPOE
Computer alerts
Warnings/reminders
Double check systems
Triggers (markers)
Clinical Pharmacists (high risk patients)
Bar coding
Thank you for your
participation!
Resources
Pharmacy Quality Commitmentwww.pcq.net
UW Center for Health Sciences Interprofessional Education
http://interprofessional.washington.edu/ptsafety/
National Patient Safety Foundation
www.npsf.org
Joint Commission
www.jcaho.com
National Coordinating Council for Medication Error Reporting & Prevention
www.jointcommission.org
Institute for Safe Medication Practices
www.ismp.org
68
The Pharmacy’s Role in Reducing
and Preventing Medication Errors:
What are the Real World Issues?
Richard B. Greene, PharmD, MBA, FASCP
Vice President of Government Affairs & Pharmacy Relations
