L11.Causes of Medication Errors

Step 4: Causes of Medication Errors

• Impact of Medication Errors

  • Varying consequences: minor distress to long-term damage or death.

  • Results in longer hospital stays and increased healthcare costs.

  • Legal costs from lawsuits add further financial burden.

  • Erosion of trust in the medical community.

• Calculation Errors

  • Originates from math mistakes by doctors, pharmacists, nurses.

  • Even calculators are prone to human error; accuracy of inputs matters.

  • Emphasis on real-time questioning of calculations to evaluate soundness.

  • Double-checking is vital: pharmacists should verify prescribing physicians’ calculations and vice versa.

• Decimal Points

  • Critical to ensure correct placement, as it can alter dosages by factors of ten.

  • Common entry mistakes can lead to grave errors: ( 0.1 ) vs. ( .1 ).

  • Handwritten decimals must be bold and clear to prevent confusion.

  • Numbers written without decimal points can lead to misinterpretations.

• Abbreviations

  • Incorrect abbreviations may cause misunderstanding; Joint Commission offers guidelines.

  • Official "Do Not Use" list includes dangerous abbreviations:

    • U: Confusion with zero, four, or "cc" ➜ use "unit."

    • QD, QD, etc.: Confused with QOD ➜ use "daily."

    • Abbreviations like MS, MSO4, etc. can confuse morphine and magnesium sulfate.

  • Additional abbreviations to avoid, including common misinterpretations.

High-Alert Medications

• Definition

  • Certain medications require extra attention due to potential harm.

  • Includes heparin, opiates, narcotics, insulin.

• Prescribing Errors

  • Occur due to various factors including:

    • Verbal orders, bad handwriting, incorrect drug strength.

    • The need for clarity and patient safety is emphasized.

• Verbal Orders

  • Verbal prescriptions should only be taken under exceptional circumstances, and pharmacy technicians must record and verify them.

  • Complex chemotherapy regimens should never be communicated verbally.

• Bad Handwriting

  • Poor penmanship is a real danger, often leading to errors due to mistaken drug names.

  • Pharmacists must clarify unclear prescriptions.

  • Electronic prescriptions mitigate this problem.

• Course Dose vs. Daily Dose

  • Chemotherapy may involve confusion between course dosing and daily prescriptions.

  • Pharmacy technicians must remain vigilant and ask for clarification as needed.

Manufacturer Errors

• Look-Alike and Sound-Alike Drug Names

  • Drug names must be distinctive to avoid confusion; FDA monitors these attributes.

  • Reported cases where patients received the wrong drug, leading to severe consequences.

• Product Labeling

  • Labels must be clear but can be hindered by aggressive marketing strategies.

• Compounding and Drug Preparation Errors

  • Compounding requires precise technique and protocol; errors can occur if proper steps aren’t followed.

  • Triple-checking, focusing on one order at a time, and following labeling guidelines help reduce risk.

Systematic Errors

• Operational Failures

  • Some errors arise from systemic issues rather than individual mistakes, highlighting the importance of good organizational practices.

  • Failure Mode and Effects Analysis (FMEA): A system for analyzing processes to identify and mitigate potential errors.

    • Steps include mapping the process, identifying possible failures, analyzing causes/consequences, and prioritizing solutions.

• Multiple Check Systems

  • Implementing a multiple-check system can significantly reduce errors, especially with high-alert medications.

  • Standardized Forms: Using standard medication orders can also mitigate errors in writing.

Reporting and Communication

• MedWatch

  • FDA’s safety reporting system for adverse events and recalls since 1993 helps share critical information with the health community.