Medication Safety
Errors occur mostly back of lack of care and concern on the part of our caregivers (T/F)
False. Most errors occur instead as a result of chain of events set in motion by a faulty system design that either induces errors or makes them difficult to detect People in healthcare are the most educated and dedicated workforce in any industry. Problem is not bad people but that the system needs to be made safer
What is the method to design effective risk-mitigation strategies?
Using the hierarchy for effectiveness - Use multiple strategies, preferring high leverage strategies targeting the system over low leverage strategies that only target the individual persons
Define Medication Error
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
Name the principle of stock taking for inventory control to prevent wrongful dispensing
''First in, First out'' - Later expiry date products at the back, all new batches at the front
Central feature/focus of a Root Cause Analysis is.....
''Systems approach to error'' - Focusing on system causes rather than blame
What may a Medication Error result in?
1. An adverse event, in which a patient is harmed 2. A near miss, in which a patient is nearly harmed 3. Neither harm nor potential for harm (errors that occur but did not harm the patient)
Familiarise with some types of Medication errors
1. Dose omission - Failure to administer an ordered dose before the next scheduled dose (excludes patients that refuse to take medications/decision not to administer) 2. Improper dose (overdose/underdose/extra dose) 3. Wrong strength; Drug; Dosage Form; Technique (inappropriate crushing of tablets); Route of administration; Rate; Duration; Time (outside predefined time interval); Wrong Patient 4. Monitoring Error: DDI, Drug-food interactions; documented allergies; Drug-disease interaction; Clinical error (wrong measurement of blood glucose; prothrombin; blood pressure) 5. Deteriorated Drug Error (Expired Drug or spoilt drug) - e.g. Infusion fluids should be clear
Why is fault finding in people unproductive in resolving an error in the medication use-process?
1. Errors occur not due to bad persons, but due to errors built into the system that allowed it to happen 2. Single events are due to convergence of multiple contributing factors instead of the individual 3. Important to target the system and address latent errors instead of blaming the individual (does not change the causative factor, same error will recur again)
How can prescribing go wrong?
1. Inadequate knowledge about drug indications and contraindications 2. Not considering individual patient factors (allergies, pregnancy, comorbidities, other medications) 3. Wrong patient, wrong dose, wrong time, wrong drug, wrong route 4. Inadequate communication (written, verbal) 5. Documentation - illegible, incomplete, ambiguous 6. Mathematical error when calculating doses 7. Incorrect data entry when using computerized prescribing (Duplication, omission, wrong number)
How can monitoring during the Medication Use Process go wrong? (Last step)
1. Lack of monitoring for ADRs 2. Drug not ceased if not working, or course completed 3. Drug ceased before course completed 4. Drug levels not measured or not followed up (e.g. Aminoglycosides; Vancomycin) 5. Communication Failures
List the 4 main factors contributing to how errors will occur?
1. Patient Factors - Patients w polypharmacy and/or multiple comorbidities/allergies etc - Patients with more than 1 doctor/specialty - Patients with specific conditions (renal impairment, pregnant) - Patients who cannot communicate well; participates poorly in own medication use - Children/babies = require dose calculation 2. Medication/Technology design factors - Poor drug manufacturing/distribution practices such as Look-alikes/sound alikes, inaccurate labels, distracting symbols/logo, similarity in colour/shape/size to another pdt - Complex/poorly designed technology e.g. Malfunction of devices; wrong device selected (not using handihaler with Spiriva), wrong usage of measuring devices and infusion pump unfamiliarity 3. Staff/Human Factors - Including but not exclusive to : failed communication (confuse drug of similar names/concentrations), distractions, lack of manpower, poorly trained staff, fatigue/boredom/lack of double checking, poor teamwork 4. System/Workplace Factors - Absence of safety culture, inadequate training, inadeqaute staffing, breakdown of information systems (computer), distractions/too many duties, poor delegation of work
How can dispensing go wrong in the medication use process?
1. Poor inventory control (messy storeroom, messy shelf, no stock taking) 2. Labelling or packaging mix-up 3. Transcription error - If there is a need to transcribe physical prescription forms into electronic systems for dispensing 4. Failure to check for individual patient factors, such as allergies, pregnancy, comorbidities, other medications 5. Documentation - illegible, incomplete, ambiguous 6. Mathematical error when calculating dosage or quantities 7. Miscommunications
List the 10 steps to reduce errors outlined by the MOH Medication Safety Guidelines
1. Reduce Reliance on (Human) Memory 2. Simplify processes/Procedures 3. Standardise Processes/Procedures/Communications e.g. Abbrievations 4. Use Forcing and constraint Functions 5. Use protocols and checklists wisely 6. Improve access to information 7. Reduce Reliance on vigilance (due limited human attention span) 8. Reduce Handoffs 9. Differentiate: Eliminate Look-alikes/sound-alike 10. Automate CAREFULLY (e.g Computerised Order Entry - CPOE)
When assembling a team to conduct RCA, what should the team comprise of?
1. Usually 4 to 6 people at least 2. Interprofessional 3. Includes individuals at all levels of organization, close and have knowledge of issues and processes in the incident
What are the 3 questions addressed and answered when conducting a RCA?
1. What happened? Describe the Key steps in the incident 2. What went wrong and why? Identify failed processes 3. What to do to prevent incident recurrence? Suggest risk reduction strategies and their implementation
Near Misses or Close Calls occurs ________ more often than adverse events
10 - 100 times For every 300 near misses, there are around 29 minor injuries and 1 major injury If all near misses can be studied and prevented, then minor/major injuries can be prevented
Bates et al Reported that _____% of Adverse Drug events were preventable
42%
Why are Drug Administration Errors during the Medication Use Process common but not well intercepted?
Administration errors are usually committed by 1 person - lesser avenues for double checking Hence, % of interception is much lower E.g. Administration of drug = 1 person; Checking identity of patient, reconstitution of IV drug at beside; documentation all usually done by 1 person
Define Adverse Drug Event
Adverse Drug Event Injury due to medication Preventable or not preventable - Preventable: Medication error - Non-preventable: Result of Adverse drug reaction/side effect Results in significant additional healthcare resource consumption
Define what is a Near Miss
An event or situation that could have resulted in medication error, but did not - Either by chance or through timely intervention - Referred to as close call - If ignored, may lead to medication errors (Error did not occur but could have occurred)
Familiarise with the types of patient outcome
Category A to I Category A = Circumstances or events that have the capacity to cause error (least harm) Category I = Contributed to or resulted in the patient's death (most harm)
Define Adverse Drug Reaction
Any response to a medication that is noxious and unintended - Includes injuries that are judged to be caused by the drug; excludes injuries due to drugs that are caused by errors - E.g. Allergic reactions in a patient taking a medication for the first time
According to Bates et al, out of the 42% of preventable adverse drug event, what are its causes?
Bates et al - Out of 42% of ADRs: - Ordering/Prescribing Errors (56%) - Administration Errors (34%) - Transcription Errors (6%) - Dispensing Error (4%)
Define Sentinel Events
Death or permanent bad outcome in the patient
Describe briefly the Swiss Cheese Model of Harm
Harm results when layers of defence in a system fail to prevent a hazard from reaching a patient - Latent unsafe conditions and active failures (unsafe acts) contribute to harm
What pose the greatest threat to safety in a complex system?
Latent errors or system failures - Leads to operator errors - Failures built into the system and present long before the active error - Difficult for people working in the system to see since they may be hidden in computers or layers of management - People because accustomed to working around the problem
List the 4 broad steps of the medication use process
Medication Use Process 1. Prescribing 2. Preparation and Dispensing 3. Administration 4. Monitoring
Errors during the Medication use Process (JAMA) - Prescribing Errors (39%) - Administration Errors (12%) - Transcription Errors (11%) - Dispensing Error (38%) Of the above types of errors, what is the % intercepted of those errors?
Most intercepted = Prescribing Errors Followed by Transcription and Dispensing errors However, Drug administration error occupies high % of medication error with low % interception
Where do errors in the medication use process occur?
Occurs at any point in the medication use process Consider safety at each step of medication use process
Other than the 5 Wrongs, how else can a drug administration go wrong?
Omission and failure to administer (e.g. patient not in bed when it is time for medication) Inadequate documentation/communication
Punishing/reprimandation of individuals when an error occurs is completely ineffective in preventing recurrence (T/F)
Partially false. This may sometimes be appropriate, but it is not an effective way to target latent errors in a system to truly prevent recurrence. Accumulation of latent failures makes the system more prone to future failures
Describe the 5 Rights/Wrongs of Drug administration
Right/Wrong Drug, Route, Time, Dose, Patient
State the means for an organisation to learn from error?
Root Cause Analysis is done with information obtained from an incident-reporting system
Define Side Effect
Side Effect A known effect, other than that primarily intended, relating to the pharmacological properties of medication (e.g. Opiate analgesia often causes nausea)
Define Root Cause Analysis
Systemic approach to understanding causes of an adverse event and identifying system flaws (latent errors) that can be corrected to prevent the error from happening again Better approach to target system failures versus blaming individuals by targeting system causes
