Preventing and Managing
Medication Errors:
The Pharmacist’s Role
SCENARIO
This scenario is based on a true story that demonstrates the
multiple breakdowns that can occur during the medication use
process that led to the death of an infant.
An infant was born to a mother with a prior history of syphilis.
Despite having Incomplete patient information about the
mother’s past treatment for syphilis and the current status of
both the mother and the child, a decision was made to treat the
infant for congenital syphilis.
After phone consultation with infectious disease specialists
and the health department, an order was written for one dose
of “benzathine penicillin G 150,000 units IM.”
• The physicians, nurses, and pharmacists, unfamiliar with the
treatment of congenital syphilis, also had limited knowledge
about this medication.
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• 500,000 units/kg, a typical adult dose, instead of 50,000
units/kg.
Consequently, the pharmacist also incorrectly read and
prepared the order as 1,500,000 units, a 10-fold overdose.
Owing to the lack of a consistent pharmacy procedure for
independent double-checking, the error was not detected.
The pharmacy dispensed the 10- fold overdose in a plastic bag
containing two full syringes of Permapen 1.2 million units/2
mL each, with green stickers on the plungers to “note dosage
strength.”
A pharmacy label on the bag indicated that 2.5 mL of
medication was to be administered IM to equal a dose of
1,500,000 units.
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• After glancing at the medication sent from the pharmacy, the
infant’s primary care nurse expressed concern to her colleagues
about the number of injections required to give the infant the
medication
• (since there a maximum of 0.5 mL per IM allowed in infants,
the dose would require five injections).
• Anxious to prevent any unnecessary pain to the infant, the
two colleagues decided to investigate the possibility of
administering the medication IV instead of IM
• The monograph on penicillin G did not specifically mention
penicillin G benzathine; instead, it noted the treatment for
congenital syphilis with aqueous crystalline penicillin G slow IV
push or penicillin G procaine IM.
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• Nowhere in the two-page monograph was penicillin G
benzathine mentioned, and no specific warnings regarding
“IM use only” for penicillin G procaine and penicillin G
benzathine were present.
• Unfamiliar with the various forms of penicillin G, a nurse
practitioner
• believed that “benzathine” was a brand name for penicillin G
and concluded that the drug could be administered safely IV.
• While preparing for drug administration, neither nurse noticed
the 10-fold overdose, and neither noticed that the syringe was
labeled by the manufacturer, “IM use only.”
• The nurses began to administer the first syringe of Permapen
as a slow IV push.
• After about 1.8 mL was administered, the infant became
unresponsive, and resuscitation efforts were unsuccessful
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• The three nurses involved in this case were indicted for
criminally negligent homicide in the death of the baby.
 There are different failures in the system that allowed this
error to occur, go undetected, & ultimately, reach a healthy
newborn child, causing his death.
 Had even just one of these failures not occurred, either the
accident would not have happened, or the error would have
been detected and corrected before reaching the infant.
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ORDERING MEDICATIONS
• Physicians —pharmacists, nurse, physician assistants, initiate
the drug dispensing and administration process through a
medication order or prescription.
• Errors in ordering medications or writing prescriptions occur
because of a lack of knowledge or poor performance by the
prescriber.
• Computerized prescriber order-entry (CPOE) are being
implemented in more settings,
• Pharmacists still dispense from handwritten medication
orders.
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Medications errors made by nurses, pharmacists, pharmacy
technicians:
1. Illegible handwriting
2. Look-Alike Drug Names
3. Sound-Alike Names
4. Ambiguous Orders, or incomplete handwritten prescriptions
5. Abbreviations to avoid
6. Similarity packaging
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Ambiguous Orders
I. Decreased doses
• A patient had been receiving 80 mg prednisone daily for
several months.
• The last visit, the physician decided to decrease the daily
dose by 5 mg, from 80 to 75 mg, and wrote the order, “Decrease
prednisone—75 mg.”
• The order was misinterpreted as meaning 80 mg minus 75mg
and was transcribed as, “Prednisone 5 mg daily.”
• A 5-mg dose was given, and the unintentional sudden large
decrease in dosage caused patient to collapse.
• “Decrease prednisone by 5mg daily” is clearer, but the safest
way to write the order is:
“Decrease prednisone by 5 mg daily. New dose is 75 mg daily.”
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II. Tablet strengths
• Orders specifying both strength and number of tablets are
confusing when more than one tablet strength exists.
• For example, “Metoprolol 1/2 (one-half ) tablet 25 mg once
daily” appears clear enough.
• However, when you realize that this product is available in
both 25- and 50-mg tablets, the ambiguity of this order
becomes apparent.
• What is the intended dose, 25 or 12.5 mg? Orders are clearer
if the dose is specified regardless of the strengths available
(e.g., “Metoprolol 12.5 mg once daily”).
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 For doses that require several tablets or capsules, the
pharmacy label should note the exact number of dosage units
needed.
For example, the label on an 800-mg dose mesalamine,
which is available only in
400-mg tablets, should read “2 × 400-mg tablets = 800 mg.”
 For a dose of carvedilol, which is available in 3.25 mg 6.25mg,
12.5-mg and 25 mg tablets.
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III. Liquid dosage forms
Expressing the dose for liquid dosage forms in only milliliters or
teaspoonfuls is dangerous.
For example, acetaminophen elixir is available in many strengths,
Including 80, 120, and 250 mg per 5 mL.
If wrote “5 mL,” the intended number of mg would be unclear.
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IV. Injectable medications
• For injectable drugs, the same rule applies.
• List the metric weight or the metric weight and volume,
• Never the volume alone, because solution concentrations can
vary.
• An example of this error occurred at a hospital where
hepatitis B vaccines were being administered.
 A preprinted physician’s order form was used to prescribe the
vaccine, listing only the volume to be given.
When the clinic switched to another brand of vaccine,
containing a different concentration of vaccine, the same
preprinted forms continued to be used.
•
This resulted in the under dosing of hundreds of children
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V. Variable amounts.
•
A drug dose never should be ordered solely by
number of tablets, capsules, ampules, or vials
because the amounts contained in these dosage
forms vary.
• Drug doses should be ordered with proper unit
expression ( “20 mEq potassium chloride”).
• A patient whose doctor orders “an amp” of KCL
might get 10, 20, 30,40, 60, or 90 mEq.
• The higher doses of this drug could be lethal.
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VI. Zeros and decimal points
When listing drug doses on labels or in other communications,
never follow a whole number with a decimal and a zero.
For example
• Warfarin 1.0 mg is a very dangerous way to express this
dose.
• If the decimal point were not seen, the dose would be
misinterpreted as “10 mg,” and a 10-fold overdose would result.
• The proper way to express this order would be Warfarin 1mg
Another example
• Digoxin 0.125 mg would be good,
• but Digoxin 125 mcg would be better.
• Use 500 mg instead of 0.5 g
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VII. Spacing
Two overdoses were reported because a lowercase l (ell) was
the final letter in a drug name and was misread as the number 1.
In one case, an order for
• Tegretol 300 mg 2 times appeared as “Tegretol 300 mg bid”
and was misinterpreted as “1300 mg bid”
In another case,
• a nurse misread an order for 2 mg Amaryl as 12 mg because
there was insufficient space between the last letter in the drug
name and the numerical dose.
when labels are printed, make sure that there is a space after
the drug name, the dose, and the unit of measurement.
• It is difficult to read labels when the drug name and dose
run together.
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Abbreviations to Avoid
Certain abbreviations are easily misinterpreted.
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D/C is another example of an abbreviation that
Should not be used.
It has been written to mean either
“discontinue” or “discharge,” sometimes resulting
in premature stoppage of a patient’s medications.
the “d/c” order was incorrectly interpreted as
“discontinuation”
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Similarity packaging
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Selecting Auxiliary Labels
• To help prevent errors and improve patient outcomes,
pharmacists and technicians should apply auxiliary labels
especially in the community setting.
•
Example, amoxicillin oral suspension is available in dropper
bottles for pediatric use.
• When the suspension is used for an ear infection, some
parents have been known to place the suspension in the
child’s ear rather than to give it (orally).
•
An auxiliary label, “For oral use only,” would help to prevent
this administration error.
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PATIENT COUNSELING AND EDUCATION
• The patient is the last individual in the medication
use process
• The pharmacist–patient interface can play a
significant role in capturing medication errors before
they occur.
• Unfortunately, many health care organizations do
not take advantage of this key interaction.
• Three important factors play a role in any patient
interface and often determine the outcome of error
prevention efforts. These include
1. direct patient education,
2. health care literacy, and
3. patient compliance.
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• In 2001, the number of retail prescriptions was 3.3 billion,
which is an increase from 2.7 billion in 2000.
• By 2005, this figure neared 3.4 billion prescriptions
• This increase in prescription volume, when combined with the
shortage of pharmacists, often results in a decrease in the
amount of time available for direct pharmacist involvement in
patient education.
• A study involving community pharmacies in eight states
revealed that 87 percent of all patients received written
information with their prescriptions.
However, only 35 % of pharmacists made any reference to the
written leaflet, and only 8 % actually reviewed it with the
patient.
• Contributing to this gap in patient education is the failure to
provide the patients with understandable written instructions.
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• The second factor is patient literacy includes
general literacy levels and health care literacy.
• Many people have difficulty understanding
their illness or disease, proper management of
disease, and their role in maintaining their
health.
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MARKETING
AND
CONCEPTS
MARKETING:
DEFINITIONS AND CONCEPTS
“Marketing is an organizational function and
a set of processes for creating, communicating
and delivering value to customers and for
managing customer relationships in ways that
benefit the organization and its stakeholders.”
• Other concepts, such as the four P’s of the
marketing mix
• Product,
• Price,
• Place (distribution),
• Promotion
• and the concept of exchange are implicit in
this definition
NEEDS, WANTS, AND DEMANDS
• The marketing concept and the definitions of
marketing discussed previously suggest that
marketers must attempt to understand the
needs, wants, and demands of their target
markets.
A need is a state of felt deprivation
•
Needs are basic human requirements.
• People have physical needs
(e.g., food, clothing, and shelter), social needs (e.g., the
need for affection and the need to belong), and
individual needs (e.g., the need for self-expression).
A want is a desire for a specific satisfier of a need.
Thus needs become wants, and these wants are
shaped by culture and individual personality.
• A need for food can translate into wanting pizza;
• A need for affection may result in wanting a hug.
A demand is a want that is backed by an ability to pay
Many people may want a vacation at a 5 STARA resort,
but only a relative few are able and willing to purchase
such a vacation.
• One problem faced by health care providers is that people
often do not want their goods or services.
This situation is called negative demand
Negative demand occurs when a major part of the market
Dislikes the product and may even pay a price to avoid it.
• There are numerous examples of negative goods besides
pharmaceutical products and services, including automobile
repair services, legal services, and dental work.
• One way to manage negative demand is to try to better
understand people’s true motivations for purchasing a product.
For example,
most people use medications not for the sake of using
medications but because those medications provide benefits by
alleviating, eliminating, or preventing a disease or symptoms.
• For example, using medications properly can allow a person to
return to work or to perform activities that he or she enjoys
doing.
• From the health economics literature, need is defined
• as “the amount of medical care that medical experts believe a
person should have to remain or become as healthy as possible,
based on current medical knowledge”
Economists are quick to point out that need is only one
factor affecting the demand for care; demand for medical
care is determined by a set of patient & provider factors,
including a patient’s need for care
Thus demand for care can be
greater than the need;
likewise, demand for care can be less than the need.
Some might argue that
• certain lifestyle drugs such as Viagra are good examples
An exchange
is a process of obtaining a desired product from
someone by offering something in return.