Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Medication Safety:
Preventing and Managing
Medication Errors
Nancy L. Losben, R.Ph., CCP, FASCP, CG
Chief Quality Officer,
Omnicare, inc
NADONA July, 2012
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Objectives
 List the major pitfalls contributing to medication
errors
 Perform a root cause analysis of a medication error
 Outline the elements to be included in the
documentation of a medication error
 Formulate a process to minimize the risk of
medication errors at transitions of care
 Develop a quality action plan to address, prevent, and
monitor medication errors
NADONA July, 2012
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It takes less time to do a thing right than
it does to explain why you did it wrong.
~Henry Wadsworth Longfellow
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
North East Division
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Institute of Medicine - 2006
 Medication errors harm 1.5 million annually
 400,000 in hospitals
 800,000 in LTC
 530,000 among Medicare Beneficiaries in out-patient
settings
 Medication related deaths/year
 40,000 – 100,000
 A majority of medication errors occur when patients are
at transition or interfaces (2)
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Why so many in Long Term Care?
 Number of medications used
 An at-risk population
 Cognitive impairment, poor patient recognition of their
medications
 Errors of omission – 56%
 Dose related errors – 25%
 Any overdose may be toxic
NADONA JULY, 2012
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Nursing home medication errors involve a
number of different circumstances
• Lack of proper patient
assessment
• Lack of monitoring for
medication's efficacy
• Lack of reassessment for
continuous need for
medication
• Lack of monitoring for
adverse drug reactions (ADRs)
• Lack of recognition of ADRs
• Attributing symptoms of ADRs
to other causes
• Inadequacies in staff
education or training
• Nursing home employees
stealing medication
Administering medications late
• Missing a medication and
giving double dosage at a later
time
• Administering the wrong
medication
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Nursing Home Adverse Events
 49% - when caregivers fail to monitor adequately
 Inadequate lab monitoring
 Failure or delay in responding to symptoms or signs of
drug toxicity
 Prescribing errors
 Wrong dose
 Drug interactions
 Wrong choices of drug
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Case Study #1
NADONA July 2012
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Case Study #1
No Error Ever Stands Alone
 Order for a blood pressure medication Zebeta® filled





with Diabeta ® 2.5 mg used to treat diabetes.
Pharmacy mis-interpretation
Facility perpetuated the order
Prescriber signed
Patient received both drugs for 20 days.
Patient hospitalized with low blood sugar
What happened?
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NADONA 2012
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Root Causes of our Serious
Dispensing Occurrences
 Systems & Methods
 Lack of training
 Depending on a
Pharmacist to catch
our mistakes
 Mixed items on the
shelf
 Over riding bar codes
 Over riding clinical
warnings
 Human Factors
 Inattention
 Distraction
 Interruptions
 Multitasking
 Rushing
 Fatigue
NADONA 2012
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Conclusion
 Most medication occurrences are due to
problems in the system or processes of how we
do things, NOT from personnel issues
 Focus on improving the “process” or steps in
care delivery, not individual performance.
 Our Medication Occurrence Prevention and
Reporting Program is not punitive; setting the
appropriate attitude and environment is
critical.
 Your participation is the only way to protect our
Residents, our Employees, our Corporation
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Approaches to Accuracy
 Read, read, read
 Be deliberate
 Focus, avoid interruptions, avoid fatigue
 Never guess when you are not sure of information you
are entering
 Check your input against the order
 Double check your calculations
 Two nurses
 Use drop down boxes where provided
 Don’t be afraid to document your work on the order
received from the facility with name, date and time of
day
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Order Entry
 A new essential function of electronic records
 Accuracy is imperative
 Right Resident (name and patient number)
 Right Facility (location, room, bed #)
 Right Drug
 Right Strength
 Right Directions (sig codes)
 Right prescriber
 Use of Stop Orders for limited duration of therapy
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
The Long Term Care Perspective
Skilled & Assisted Living Centers
 Medications are the mainstay of treatment in the
chronically ill
 LTC residents may take eight or more medications
every day
 Comorbidities complicate the outcome of medication
errors in our already- compromised residents and
guests
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LTC Pitfalls in
Medication Errors
 Communication
 Name Confusion
 Labeling and Packaging
 Human Factors
 Systems Related Factors
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Long Term Care Pitfalls Cause: Verbal Communication
 Verbal miscommunication - in person or by telephone
 “Whisper down the lane” effect - Physician, to nurse, to
pharmacist
 Accents, dialects, pronunciation
 Background noise, interruptions
 Unfamiliar terminology
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Safe Verbal Communication
 Enunciate clearly
 Receiver must repeat the order
 Spell unfamiliar drug names
 Ensure the order makes sense
 Record the verbal order immediately
 Sign, date, and time the verbal order
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Safe Verbal Communication
 Obtain the caller’s phone number
 Obtain indication or reason for use
 Limit the number of personnel who
can take a verbal order
 Have a registered pharmacist receive
all verbal orders
 Fax complex orders
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Paris in the
the spring
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Diabeta?
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Long Term Care Pitfalls –
Cause: Written Communication
 Poor handwriting
 Interpretation, mis-read, not read
 Omission of important information
 Abbreviations
 Non-metric units
 Trailing and leading zero’s
 Decimal Points
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Long Term Care Pitfalls - Written
Communication
 Pharmacy-generated, computerized physicians order
sheets, MARS & TARS
 Fax machines
 Copy machines with extraneous markings
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Safe Written Communication
 Legible handwriting
 Computerized prescribing technology
 Computers at nurses stations
 Palm technology for physicians
 Complete orders including strength
 Include indication and reason for use
 Standardized abbreviations
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Unsafe Abbreviations
Examples
Standardize a
list of
abbreviations,
acronyms,
symbols and
dose
designations
NOT to be
used in your
organization
U or u
q.d or QD
Unit
Every day
MS, MSO4, Morphine Sulfate
MgSO4
Magnesium Sulfate
> Or <
Greater than
Less than
A.S., A.D., Left ear, right ear,
A.U
both ears
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Safe Written Communication
 Policies and Procedures for computerized physicians
orders
 Business machines clean & in good working order
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Long Term Care Pitfalls Name Confusion
 Look-alike, sound-alike, 25% of all
errors
 Brand names
 Generic names
 Over the counter products
 Safety with medication names
 Repeat the order
 Ask “Is that correct?”
 Include indication or reason for use
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Lillian
Williams
Gillian
Williams
Glyburide-Glipizide
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Look-alike / Sound-alike
Examples
Flomax®
Fosamax ®
Morphine Concentrate
Morphine solution
MS Contin ®
Oxycontin ®
Proscar ®
Prozac ®
Serzone ®
Seroquel ®
Wellbutrin SR ®
Wellbutrin XL ®
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
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Omnicare of Southern, NJ
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Long Term Care Pitfalls Labeling and Packaging
 Wrong resident name
 Wrong drug name or strength
 Wrong directions
 Incomplete directions
 Lack of or wrong ancillary directions
 Looks too similar to another product
 Controlled substances packaging & documentation
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Safe Labeling and Packaging
 Procedure for receipt of medications from the
pharmacy
 Check all new orders against the physicians order
 Check each prescription label against the MAR and
TAR
 Check each tablet identifier against the
prescription label
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Long Term Care Pitfalls The Human Factor
 Knowledge deficit, Poor performance
 Miscalculation of dosage
 Incorrect infusion rate
 Data entry error
 Failure to prepare a medication properly
 Cart preparation
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Long Term Care Pitfalls The Human Factor
 Stress
 Workload
 Fatigue
 Learning curve for electronic health records/orders
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Long Term Care Pitfalls Systems Related
 Emergency box use
 Lighting and noise
 Interruptions and distractions
 Training
 Adequate staffing
 Availability of physician or pharmacist
 Policies and Procedures
 Medication Reconciliation
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Warfarin Drug Interaction
 Warfarin interacts with
many antibiotics!
 Did you remind the
prescriber the resident
uses warfarin?
 Do not remove the
antibiotic until you check
with the prescriber or the
pharmacist
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Possible Allergic Reaction!
 Check for drug allergies to
before removing any dose
from the emergency
medication supply.
 Not sure? Call and speak
with a pharmacist.
Long Term Care Pitfalls Systems Related
 Drug delivery and distribution systems
 Title 22 in California
 CMS regulations
 Polypharmacy
 Stop order policies
 E-Prescribing
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E-Prescribing Pitfalls
 Structured and free text fields
 Drug line, Directions line, Special Instructions
 Complex regimens
 PRN
 Sig to time conversions for administration times
 Duration of therapy
NADONA July, 2012
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
The Dreaded Controlled
Substance Prescription for a
Resident in Pain
NADONA July, 2012
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Medication Reconciliation
 Any change in care: settings, service, practitioner, level
of care
 50% of all medication errors occur at transition of care
IV meds
OTC meds
Prescription medications
TPN
Vitamins
Vaccines
Nutritional Supplements
•Complete list of current medications
•Validate with patient, if possible
•Use a consistent form
• designate responsibility
•Reconcile within 24 hours
•Reconcile sooner if using high risk medications
•Provide discharge medication information
•Develop a policy and procedure
•Teach it
NADONA July, 2012
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Detecting Medication Errors
 Receiving and checking drug deliveries
 Monthly Physician Order Recapitulation
 Reconciling Product to MAR and TAR
 Chart Audits
 Recognizing Adverse Drug Reactions
 Resident Complaint
 Resident Change of Status
 Abnormal labs
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Preventing Medication Errors
 Report errors
 Trend types of errors
 Document outcomes
 Analyze causes
 Take action
 Monitor success
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Reporting Medication ErrorsThe Event
When?
 Date
 Week day, weekend, holiday
 Time of day error occurred
 Which med pass?
 Initial report date
 Follow up report date
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Reporting Medication ErrorsThe Event
 Setting
 Post acute unit, chronic care
 ALF, Adult day care, dementia unit, other
 Home on LOA
 Pharmacy
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Description of Event
 Record immediately
 So you won’t forget
 A Narrative in your own words
 No opinions- Just the fact, ma’am!
 How discovered
 How perpetuated
 1 pharmacy error or 30 NF errors
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Description of Event
 Labs performed, date(s) of additional therapy
 Indication for use
 Medical intervention necessary
 Immediate corrective action
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Resident Outcome
 No Harm
 Harm
 Categories of harm
 Death
 Sentinel Event
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Categories of Harm
 Category E: Error resulted
•Category A: No Error
•Category B: Error
occurred but medication
did not reach resident
•Category C: Error
reaches resident, but did
not cause harm
•Category D: Error
occurred that resulted in
monitoring, but no
resident harm




in need for treatment or
intervention and caused
temporary harm
Category F: Error resulted
in initial or prolonged
hospitalization and
caused temporary harm
Category G: Error resulted
in permanent harm
Category H: Error resulted
in near-death event
Category I: Error resulted
in death
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Reporting Medication Information
 Name of drug
 Brand name, generic name
 Strength, frequency, route
 Prescription, OTC, Investigational
 New admission order
 Failed medication reconciliation
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Reporting Medication Information
 Therapeutic class
 Name of manufacturer
 Dosage form
 Package type
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
Personnel Involved
 Who made the error
 Who discovered the error
 Physician, Nurse Practitioner
 Nursing assistant/medication assistant
 Pharmacist, pharmacy technician
 Respiratory Therapist
 Physical Therapist
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Type of Error
 Omission
 Wrong resident, drug, strength, time, route, dosage
form
 Wrong technique
 Wrong rate of infusion, wrong duration
 Monitoring error
 Allergy, drug-drug interaction, drug-food
interaction, drug-disease interaction, clinical
 Expired drug
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Reporting an occurrence is
a non-punitive event…
Reporting helps us to
prevent it from happening
again!
Reporting helps us find the
best way to do things!
NBADONA July, 2012
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
“If we do not all hang together,
surely we will all hang
separately.”
Benjamin Franklin
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Thank You!
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References
1.
2.
3.
4.
5.
Medication Reconciliation and error prevention. The Pharmacist’s Letter.
Improving patient safety: medication reconciliation basics, Volume 2010,
No. 303
Turchin, A, et al. Unexpected effects of unintended consequences: EMR
prescription discrepancies and hemorrhage in patients on warfarin. Oct. 22,
2011 http://www.ncbi.nlm.nih.gov/pubmed/22195204
Palchuk, MB., et al. An unintended consequence of electronic prescriptions
and impact of internal discrepancies. J Am Inform Assoc 2010:17:472476/JAMA 2010, 003335
Electronic health records. CMS. http://www.cms.gov/Medicare/EHealth/EHealthRecords/index.html?redirect=/EHealthRecords/ Accessed
May 27, 2012
ISMP List of High Alert Drugs. ISMP 2012.
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Medication Errors: The Other National Drug Problem
July 22, 2012
12:30-2:00pm
References
6. CMS. Electronic Health Records http://www.cms.gov/Medicare/EHealth/EHealthRecords/index.html?redirect=/EHealthRecords/
Accessed 3/26/2012
7. 2012 National Patient Safety Goals, The Joint Commission, Jan. 19,
2012
8. Fick, DM., Semla, TP 2012 American Geriatrics Society Beers
Criteria: New Year,New Criteria, New Perspective, Jags, 2012
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