DEFINITION:

A medication error’s is any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in control of 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 labelling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use.¹

Sources of Medication Error

· Inaccurate recording and transcribing orders.

· Unclear or erroneous labeling of drugs

· Misidentification of client

· Incomplete delivery of drugs

· Verification errors

· Use of inadequate knowledge or inaccurate knowledge base.

Causes :

· Oral and written miscommunication

· Name confusion (illegible prescribers handwriting)

· Similar or misleading container labeling

· Performance (excessive workload/staffing inadequacies) or knowledge deficit

· Inappropriate packaging or device design (flawed dispensing system)

Classification of Medication Error

· The medication error may be classified in to mistakes, slips, or lapses.

· Medication errors may also be classified according to where they occur in the medication use cycle, i.e. at the stage of prescribing, dispensing, or administration of a durg.

Figure 1:Types of Medication Error

There are four broad types of medication errors

· Knowledge-based errors (through lack of knowledge) —for example, giving penicillin, without having established whether the patient is allergic.

· Rule-based errors (using a bad rule or misapplying a good rule)—for example, injecting diclofenac into the lateral thigh rather than the buttock. Proper rules and education help to avoid these types of error, as do computerized prescribing systems.

· Action-based errors (called slips)—for example, picking up a bottle containing diazepam from the pharmacy shelf when intending to take one containing diltiazem. A subset of action-based errors is the technical error—for example, putting the wrong amount of potassium chloride into an infusion bottle. This type of error can be prevented by the use of checklists, fail-safe systems and computerized reminders.

· Memory-based errors (called lapses)—for example, giving penicillin, knowing the patient to be allergic, but forgetting. These are hard to avoid; they can be intercepted by computerized prescribing systems and by cross-checking.²

Prescribing Errors

Contributing Factors Include

· Lack of knowledge of the prescribed drug, its recommended dose, and of the patient details contribute to prescribing errors.

· Illegible handwriting.

· Inaccurate medication history taking.

· Confusion with the drug name.

· Inappropriate use of decimal points. A zero should

· Always precede a decimal point (e.g. 0·1). Use of a trailing zero (e.g. 1·0).

· Use of abbreviations (e.g. AZT has led to confusion between zidovudine and azathioprine).

· Use of verbal orders.

Approaches for Reducing Prescribing Errors

· All prescription document should be legible. Verbal orders should be minimized

· Prescription should include a brief notation of purpose (eg. cough).

· Prescription to be written in metric system except for therapies that use standard units

· Dose of oral liquid to be expressed using only metric weight or volume . Eg. Mg/Ml

· Prescriber should include Patient reported age and weight on prescription or medication order

· Electronic prescribing may help to reduce the risk of prescribing errors resulting from illegible handwriting

· Computerized physician order entry systems eliminate the need for transcription of orders by nursing staff

· Tall Man Lettering system-writing part of drug names in upper case letters to help distinguish sound alike look alike drugs from one another. Eg: niMODIpine/ niFEDIpine, metaPROLOL, bisoPRLOL

Dangerous Abbreviations

Abbreviations	Intended Meaning	Common Error
U	Units	Mistaken as zero/4/cc
ug	Microgram	mg
QD	Everyday	Qid (four times daily)
QOD	Every other day	QD/QID
SC	Subctaneous	SL
TIW	Three times a week	TID
HS	Half Strength	Hs (Hour of sleep)
IU	International Unit	IV (Intravenous)/10
MS, MSO4, MgSO4		Morpihne Sulphate or Magnesium Sulphate

Dispensing Error

· From the receipt of the prescription in the pharmacy to the supply of a dispensed medicine to the patient.

· This occurs primarily with drugs that have a similar name or appearance.

· Example :lasix® (frusemide) and losec® (omeprazole)

· Other potential dispensing errors include wrong dose, wrong drug, or wrong patient

Approaches for Reducing Dispensing Error

· Ensuring a Safe Dispensing Procedure.

· Separating drugs with a similar name or appearance.

· Keeping interruptions in the medicine administration procedure to a minimum and maintaining the workload of the nurse at a safe and manageable level.

· Awareness of high risk drugs such as potassium chloride and cytotoxic agents.

· Introducing safe systematic procedures for dispensing medicines in the pharmacy.

· Circulate posters on product changes so that all pharmacy staff will know that certain medications has changed in appearance.

Administration Errors

· Discrepancy occurs between the drug received by the patient and the drug therapy intended by the prescriber.

· Errors of omission - the drug is not administered

· Incorrect administration technique and the administration of incorrect or expired preparations.

· Deliberate violation of guidelines

Causes of Administration Errors

· Lack of perceived risk

· Lack of available technology

· Lack of knowledge of the preparation or administration procedures Complex design of equipment.

Contributing Factors to Drug Administration Errors

· Failure to check the patient’s identity prior to administration

· Environmental factors such a noise, interruptions ,poor lighting

· Wrong calculation to determine the correct dose

Approaches to Reduce Drug Administration Errors Include:

· Checking the patient’s identity.

· Ensuring that dosage calculations are checked independently by another health care professional before the drug is administered.

· Ensuring that the prescription, drug, and patient are in the same place in order that they may be checked against one another.

· Ensuring the medication is given at the correct time.

· Minimizing interruptions during drug rounds

Action to be Taken When Error Occurs

· The client safety becomes the top priority

· The nurse assesses and examines the client’s condition and notifies the physician of the incident as soon as possible.

· Once the client is stable the nurse reports the incident to the appropriate person in the institution like nursing supervisor or nursing manager.

The nurse is also responsible for reporting the incident. An incident report usually must be filed within 24hours of an incident

· The report includes client identifying information, the location and time of the incident, an accurate factual description of what occurred and what was done, the signature of the nurse involved. The incident report is not a permanent part of the medical record and should not be referred to in the record. This is to legally protect the health care professional and institution.

· The institution use incident report to track incident pattern and to initiate quality, improvement programs as needed.

· It is good risk management to report all medication error including mistakes that do not cause obvious or immediate harm or near misses.³

Steps to be taken in preventing medication error

· Follow the rights of medication administration

· Right patient

· Right drug

· Right dose

· Right time

· Right route

· Right recording

· Right assessment

· Right education

· Right evaluation

· Right to refuse medication

· Be sure to read labels at least 3 times, before during after administration of the drug.

· Prepare the medicine in a well lighted room.

· Check the expiry date of the drug before administration.

· Be aware about ambiguous orders or drug names and numerical and Consult doctor if any doubt.

· Be alert to usually large dosage or excessive increase in dosage ordered.

· Ensure proper storage of medication for proper efficacy

· Consider having drug guide available all the time

· Utilize a bar coding medication scanning system

When in doubt, check order with prescriber, pharmacist, literature

· Double check all calculation, even simple calculation

· Do not allow any other activity to interrupt your administration of medication to a client.

· Routinely refer to drug interaction charts or drug reference source and commit common interactive drugs to memory.

· Do not use any unstandard abbreviation and symbols, question if any one use

· Read the leaflet of the drug carefully when giving new drug first time.

· Do not make assumptions of illegible orders.

· Do not accept incomplete orders and telephonic or verbal orders.

· Double check with a client who has allergies about all new drugs as they are added in treatment plan

· Question a drug form used in unfamiliar way.

· Document all medication as soon as they are given.

· When you have made an error reflect on what went wrong ,ask how you could have prevented the error

· Evaluate the context for any medication error to determine if nurses have the necessary resources for safe medication administration.

· When repeated medication error occurs within a work area, identify and analyze the factors that may have caused the errors and take corrective action.

· Attend in-service program that focus on the drug you commonly administer.⁴

Medication Error Alert:

Alert should be issued out whenever error occurs so that information may be disseminated for others to be more careful in dealing with medications involved.this alert can be issued via mails ,memos, posters

Medication Error Report Form

· Date and time of event

· Location of event: Ward/pharmacy/OT/ICU

· Description of event: sequence of event,work environ-memt - (peak hours, change of shift), details

· In which process error occurred: prescribing/ dispensing/administration

· Did error reach patient:Y/N

· Describe direct result on patient: Death/treated error

· Possible contributing factors

· Category of staff made initial error: nurse/ doctor/ pharmacist/trainee

· Category of staff/provider or individual who discovered the error

· Patient particulars: patients name, age, sex, diagnosis

· Relevant materials can be provided: copy of treatment ,picture of product, label of product

· Recommendations or preventive actions taken

· Reporters details ⁵

CONCLUSION:

Protecting public health, promoting patient safety and reducing medication errors are important priorities .Medication error reduction programs are necessary to achieve improvement in patient care and to satisfy the public demand for a safer health care system. Therefore Programs to detect, correct and prevent errors partnered with no-fault reporting programs are essential to satisfying this end.

REFERENCES:

1. http://www.nccmerp.org/about-medication-errors

2. http://qjmed.oxfordjournals.org/content/102/8/513

1. 3.https://books.google.co.in/books

3. http://www.slideshare.net/maryline1979/medication-error-25474916

4. http://jipmer.edu.in/wp-content/uploads/2013/01/Medication-error-reporting-form.pdf

Received on 25.06.2016 Modified on 17.07.2016

Int. J. Nur. Edu. and Research. 2016; 4(4): 502-505.

DOI: 10.5958/2454-2660.2016.00094.6