E2 Intro to HC: Medication Safety and Error Prevention

Where can medication error happen during the prescription medication use process (PDAM)

At any step!!!!

what diagram do we use to see where the error occurred?

• 5 why diagram

Assessing a drug event what do we look at?

• preventability

• Level of harm

• Causality (probability)

When assessing ADE preventability there are 4 assessments, what are they?

• definitely avoidable - poor drug treatment, inconsistent w/ present day knowledge

• Possible avoidable - could’ve have been avoided (med was not erroneous)

• Not avoidable - (unpredictable)

• Unevaluable - no data or evidence was conflicting

True or false: NCC MERP index categorizes medication errors

TRUE:

NCCMERP - national coordinating council for medical error reporting and prevention!!!!!!!

• it indexes medication errors by severity

A = no error

B,C,D = error, no harm

E,F,G,H = error, harm

I = error, death

What is the causality assessment of ADR?

• evaluation of the likelihood that a suspected drug caused an adverse reaction

• Relationship between drug and the reaction

Determining causality: temporal relationship

Timing between the start of drug therapy and the reaction

Determining causality: Dechallenge

Reduce dose, hold medication or discontinue therapy

Determining causality: Exclusion

Exclude some medications and other potential factors

Determining causality: Previous reports

Established vs. new classes

The WHO-UMC causality assessment was used to evaluate what?

Used to evaluate the likelihood that a specific drug, vaccine, other medical intervention has caused an adverse event

• certain

• Probable

• Possible

• Unlikely

• Conditional/unclassified

• Unassessable/unclassificable

Terminology: define side effect

• expected well known reaction

• Result in little or no change in patient management

• Occurs with predictable frequency and whose intesity and occurrence are related to side of dose

Terminology: define Adverse drug event

• unintended physical injury resulting from or contributed to by medical care

• Required additional monitoring, treatment or hospitalization

• Can result in death

Terminology: define Adverse drug reaction

• response to a drug that is noxious and unintended

• Occurs @ normal dose

ADR require normal dose, direct and A

Difference between ADR and ADE

ADR require normal dose, direct and ADE required use of a drug, proximity

Terminology: define medication errors

• any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is then the control of the HCP, patient or consumer

Whats included in prescribing errors?

• incorrect drug selection (dose, strength, route, etc)

• Failure to comply with legal requirements for prescription writing

Whats included in dispensing errors?

• error diuring the process from the receipt of a prescription in the pharmacy through to the supply of dispensed drug

• 1-24% error

• Wrong product: look alike sound alike

Must be examined in the pharmacy and areas of stocking to prevent harm

Tall man lettering helps

What does tall man lettering help with?

Help with drugs with similar names

Whats included in administration error?

• discrepancy between drug therapy revised by the patient and the drug therapy intended by prescriber

• Highest risk areas in nursing

• Error of omission where administration is omitted due to a variety of factors

• Wrong administration technique, expired drugs, wrong prep administration

What are workarounds?

Something wrong with the system and people try to work around it

• lead to medication error

What are approaches to reduce medication errors: person centered approach

looks at medication errors as occurring due to human frailty

• Forgetfulness

• Poor motivation

• Carelessness

• Negligence

What are approaches to reduce medication errors: System center approach

• belief that errors expected to occur

• View errors as the end result and not the cause

• Beleif that there is potential for error and recurring errors in every system

• Solutions are based on belief that conditions can be changed rather than changing humans

• focusing on how and why system failed, not individual failure

Whats the Swiss cheese model of system errors?

• used to illustrate how adverse events or medication errors can occur based on multiple small system failures