Preventing and Managing Medication Errors

PREVENTING AND MANAGING
M E D I C AT I O N E R R O R S :
THE PHARMACIST’S ROLE
PRESENTED BY: LIZA MARIE C . DE GUZMAN, RPH
LEARNING OBJECTIVES
1. Define Medication Error and Categories of Error
2. Discuss the role of the pharmacists in preventing medication
errors
3. Define latent and active failures and the role each plays when a
medication error occurs
4. Define the types of medication errors that can occur during
ordering and dispensing process
5. List some commonly used drugs that can result in medication-
related deaths
6. Describe a variety of methods that can be used to identify risk and
provide meaningful data on the relative safety of their facility’s
medication use proces
7. Select high-leverage error reduction strategies
WHAT IS A MEDICATION ERROR?
Medication error is 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.
CATEGORIES OF MEDICATION ERROR
Category Description
Type A No error, capacity to cause error
Type B Error that did not reach patient
Type C Error that reached the patient but
unlikely to cause harm
Type D Error that reached the patient and
could have necessitated monitoring
an/or intervention to preclude harm
Type E Error that could have caused

temporary harm
Type F Error that could have caused
temporary harm requiring
initial or prolonged
hospitalization
Type G Error that could have resulted in
permanent harm
Type H Error that could have necessitated
intervention to sustain life
Type I Error that could have resulted to
death
•Front end or active end of the error
•Latent end or blunt end of the error
PROCESSES INVOLVED IN MEDICATION
USE:
Ordering Medications
 Illegible Handwriting
Action: encourage physicians with poor handwriting

to print prescriptions and medication orders in
block letters
SOUND ALIKE DRUGS
Buproprion Buspirone
Clomipramine Clomiphene
Dopamine Dobutamine
Ketoprofen Ketotifen
LOOK ALIKE DRUGS
Sound-Alike and Look-Alike Drugs (SALAD)
Action:
Up-to-date education on all new medications is
provided to pharmacy staff, including any potential for
error that may exist with these new products
Physicians can write both the generic name and
brand name and the intended purpose
Discourage Verbal Orders
WHEN VERBAL COMMUNICATION IS
UNAVOIDABLE….
1. Verbal orders should be taken only by authorized personnel
2. If possible, a second person should listen while the prescription is
being given
3. The order should be written down and then read back, repeating
exactly what has been ordered, sometimes spelling the drug name
for verification and the strength by using digit-by-digit technique
for the dose
4. In acute care setting, record the verbal order directly onto an
order sheet in the patient’s chart whenever possible
Abbreviations to Avoid
The abbreviation U for units

Example: Humalog6U has been misinterpreted as 60 units
Q for “every” as well as other abbreviations with this letter (QD, QID
and QOD)
Example: An order of Zithromax (azithromycin) 500 mg written as QD was
misinterpreted as QID
D/C. it has been written to either mean either discharge or

discontinue sometimes resulting in premature stoppage of a patient’s
medication
Abbreviating drugs names:
MgSO4 vs MSO4
MTX means methotrexate but some professionals
understand it as mitoxantrone
AZT misunderstood as “azathioprine”
HCT vs HCTZ
Ambiguous orders
Zeros and decimal points  Tablet Strengths

Coumadin 1.0 mg “Metoprolol ½ (one-half) tablet 25 mg
Coumadin 1 mg once daily”
“Metoprolol 12.5 mg once daily”
Leading Zeros  Liquid Dosage forms
Vincristine .4 mg Expressing the dose for liquid dosage
Vincristine 0.4 mg forms in only milliliters or teaspoonful is
dangerous
Digoxin 0.125 mg
Digoxin 125 mcg
Injectable medications  Spacing
List the metric weight of the dose, or the When labels are printed make sure that
metric weight and volume of the dose, there is a space after the drug name, the
but never the volume alone dose and the unit or measurement
Variable amount  Apothecary system
Rx Use the metric system exclusively
Potassium chloride amp
USE:
Preparing and Dispensing Medications

An important safety enhancement for
preventing dispensing errors is to develop a
system of redundant checking
COMMUNITY PHARMACY
Patient sees the Prescription reaches The

doctor the Pharmacy pharmacist/pharmacy
technician reviews the
order
The pharmacist A second review is

checks the work done by the A label and/or
of the technician technician in choosing medication
the item for profile is printed
dispensing
Patient counseling
HOSPITAL PHARMACY
Patient sees the A unit secretary A nurse checks the
doctor transcribes the transcription
order onto MAR
A pharmacy label is A pharmacist Copy is transported

printed reviews the order to the pharmacy
A second review is A pharmacist checks Medication is

done by the the technician’s delivered to patient
technician in work area
choosing an item for
dispensing
The nurse received
The nurse the ordered the
administers the drug drug
SELECTING MEDICATIONS
During drug preparation and dispensing, the label should be
read three times:
1. When the product is selected

2. When the medication is prepared
3. When either the partially used medication is disposed of
(or restored to stock) or product preparation is
complete
AUTOMATED DISPENSING CABINET
Confirmation bias – is used to describe the phenomenon
when choosing an item, people see what they are looking
for, and once they think they have found it , they stop
looking any further.
HOW TO AVOID?
Physically separating look alike drugs

Separate drugs with similar names and overlapping
strengths , especially those labeled and packaged by the
same manufacturer
Tall man lettering
chlorproMAZINE vs chlorproPAMIDE
vinBLASTINE vs vinCRISTINE
NICARdipine vs NIFEdipine
SELECTING AUXILIARY LABELS
Example:
Amoxicillin oral suspension available in dropper bottles for

pediatric use
“For oral use only”
USE:
Patient Counseling and Education
Three important factors that affects pharmacist-patient interface and

often determine the outcome of error-prevention efforts.
1. Increase in prescription volume
2. Patient literacy
3. Compliance
EFFECTIVE RISK-REDUCTION
STRATEGIES
a. Fail-safes and constraints – involve true system changes in the
design of products or how individuals interact within the system
b. Forcing functions – are procedures that create a “hard stop”
during a process to help ensure that important information is
provided before proceeding
c. Automation and computerization of medications
d. Standardization – to create a uniform model to adhere to when
performing to when performing various functions and it tends to
reduce the complexity of a specific process.
e. Redundancy – duplicate steps or add another
individual in the process
f. Reminders and checklists
g. Rules and policies
h. Education and information
i. Suggestions to be more careful and vigilant
RISK IDENTIFICATION METHODS
1. Self assessment
2. Direct observation
3. Retrospective, voluntary, confidential reporting
WHO IS ACCOUNTABLE?

Preventing and Managing Medication Errors

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PREVENTING AND MANAGING

Type E Error that could have caused

Action: encourage physicians with poor handwriting

The abbreviation U for units

D/C. it has been written to either mean either discharge or

Zeros and decimal points  Tablet Strengths

Preparing and Dispensing Medications

Patient sees the Prescription reaches The

The pharmacist A second review is

A pharmacy label is A pharmacist Copy is transported

A second review is A pharmacist checks Medication is

1. When the product is selected

Physically separating look alike drugs

Amoxicillin oral suspension available in dropper bottles for

Three important factors that affects pharmacist-patient interface and

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