Medication Safety
This module will help you
medicate your patients as
SAFELY as possible.
1
Introduction
Course Objectives:
After completing this module, the learner will be able to:
• State the SHC definitions of medication safety events (e.g.,
adverse drug events and medication errors).
• Discuss the impact of adverse drug events and medication
errors.
• Describe high risk medications and safe medication practices.
• Explain the process for reporting an adverse drug event or
medication error.
• List four practices that can prevent medication errors and
adverse events.
2
Adverse Drug Events
Outnumbering wound infections, the rate of ADEs is
estimated by researchers to be between two to
seven (2-7) events per 100 patient admissions.
These events range clinically from minor drug side
effects and allergic reactions to death.
5
Medication Errors
Medication errors may occur at any stage of the medication
process including:
• Selection/procurement/storage
• Prescribing
• Processing (communication related to processing and
transcribing orders, compounding, packaging, labeling,
dispensing and distribution).
• Administration
• Reporting/Monitoring
8
Medication Errors
Examples of errors include:
• Celebrex (anti-inflammatory) is mistaken for Celexa
(antidepressant).
• Zyrtec (antihistamine) is mistaken for Zyprexa (antipsychotic)
• .5 mg of Xanax is mistaken for 5 mg of Xanax.
• An MD’s verbal order for Toradol 15mg is mistaken for 50mg.
• Insulin 5u is mistaken for 50 units.
• Amoxicillin is ordered for a patient with a penicillin allergy.
9
Medication Error Prevention…Safer Systems!
Examples of safer systems include:
• Computerized Medication Record Systems
• Micromedex®
• Pyxis®
• Alaris® IV Pumps and Guardrails®
10
Medication Error Prevention …Safer Systems!
Designing and utilizing safer systems decreases the
number and severity of events.
Humans make mistakes, but good systems design and
continuous improvements utilizing the information obtained
from error analyses have been shown to decrease errors.
11
Medication Error Prevention…What YOU can do!
“How can I improve
medication safety?”
12
Medication Error Prevention…What YOU can do!
How YOU Can Prevent Errors!
Respect at least these 5 basic rights:
• Right patient
• Right medication
• Right dose
• Right route
• Right time
Refer to your site’s leaders for any additional guidance as to
patient rights.
13
Medication Error Prevention…What YOU can do!
TJC National Patient Safety Goal: Accurately and
completely reconcile medications across the continuum
of care.
Upon admission, we compare the medications the organization provides to the
list of the patient's current medications.
A complete list of the patient's medications is communicated to the next provider
of service when we refer or transfer a patient to another setting, service,
practitioner or level of care within or outside the organization.
Please refer to your work site for further details on realizing this goal.
14
Medication Error Prevention…What YOU can do!
How YOU Can Prevent Errors!
Complete the Admission Database. Obtain a good patient
medication history of:
• Prescription drugs and dosages
• Over-the-counter drugs and dosages
• Herbal/alternative products
• Including EVERY route! Some
patients incorrectly consider only
oral products to be medications.
• Last dose
15
Medication Error Prevention…What YOU can do!
How YOU Can Prevent Errors!
• Never accept blanket “resume all meds” orders
when transferring between levels of care
• Rewrite orders using “a medication order
summary form” or a MAR copy
• Facilitates provision of specific orders and
identifies meds which should not be continued
16
Medication Error Prevention…What YOU can do!
TJC National Patient Safety Goal: Patient Identification
Use at least two identifiers for patients prior to administering medications.
Acceptable identifiers include:
• Patient’s name, MR# or account#, date of birth
• A photo ID is appropriate in some cases (e.g., SVP, SMV, GH Behavioral
Health Service).
Note: Do not use the room number as one of the two identifiers!
This requirement also applies to:
• Blood administration,
• Taking blood and other specimens for clinical testing,
• Providing any other treatments of procedures
17
Medication Error Prevention…What YOU can do!
Sources of acceptable identifiers include:
• Patient arm/wrist band.
• Medical Record.
• Medication Administration
Records (MAR).
• Pyxis medication removal
slips.
• Pharmacy generated
medication labels.
18
Medication Error Prevention…What YOU can do!
TJC National Patient Safety Goal:
Verbal & Telephone Orders
TJC requires we read orders back to the issuer:
1. Write it down immediately…
2. Read it back, then…
3. Get confirmation that it was understood correctly!
• When in doubt, ask for further clarification:
•Examples:
• Say “one-five milligrams” to distinguish 15 mg from
50 mg (“five-zero milligrams”).
• Clarify whether an order for “nitro” is for
nitroglycerin… or nitroprusside.
19
Medication Error Prevention…What YOU can do!
HIGH-RISK meds: Be ESPECIALLY cautious!!
INSULINS
Insulin, Humulin, Novolin, Novolog, Humalog…
…70/30, 75/25, etc.!!
• These can be VERY confusing…check and re-check!
• Read every label, carefully, completely.
• Don’t hesitate to ask someone to double-check you!!
20
Medication Error Prevention…What YOU can do!
HIGH-RISK meds: Be ESPECIALLY cautious!!
INSULINS (continued)
Read the vial label very carefully to avoid confusion!
Use Sharp’s insulin reference cards on name badges and in med rooms!
• Cards compare the onsets & durations of action
• See the next slide for the card graphic
• See your supervisor for the actual card and explanation of its usage
21
Insulin Types
INSULIN EFFECT
Morning Afternoon
Evening
Night
REGULAR
ASPART (Novolog)
B
L
S
NPH
HS
LANTUS
B
MEALS
22
Medication Error Prevention…What YOU can do!
HIGH-RISK meds: Be ESPECIALLY cautious!!
INSULINS (continued)
• Dosages: Check and re-check…
• Correct transcription of the insulin brand & dosage?
• Dosages…Is that a “4” or a “9”?...Is that “2U” or “20”?
• Don’t accept orders with “U” instead of “units”!
• Label syringes after drawing up insulin…patient ID, drug name & dose
• Treat one patient at a time…draw up, administer, document…next patient
• Always ask for a double-check
23
Medication Error Prevention…What YOU can do!
HIGH-RISK meds: Be ESPECIALLY cautious!!
OPIOIDS
• Top problematic example…
Morphine is NOT HYDROmorphone (Dilaudid)!
• Safety
Pearl! …
Morphine
5
mg IV = only
1
mg IV HYDROmorphone
24
Medication Error Prevention…What YOU can do!
HIGH-RISK meds: Be ESPECIALLY cautious!!
OPIOIDS (continued)
• Names:
Roxanol, Roxicodone, Oxycodone, Oxycontin, MS Contin…
…and oxycodone, hydrocodone, codeine!!
These names are easily confused!
Stop, check and re-check!
Don’t hesitate to ask someone to double-check you!!
25
Medication Error Prevention…What YOU can do!
HIGH-RISK meds: Be ESPECIALLY cautious!!
Other high-risk meds include:
• Cancer chemotherapy agents:
• Accept verbal/telephone orders only in true emergencies
• Double-check transcription and medication against the order
• Anticoagulants:
• Heparin:
• Ask for a dosage double-check, and document it
• Use the standard order sets, dosage guidelines, and Alaris units/hr
• Warfarin:
• Orders can change frequently; check transcriptions closely!
• Paralyzing agents: READ THE LABEL…to avoid fatal errors!
26
Medication Error Prevention…What YOU can do!
Avoid problem-prone abbreviations or dosage expressions:
These abbreviations must always be clarified before carrying
them out, except in emergencies.
Error-prone…
DON’T Use!
No zero before
medication decimal
dose
(e.g., .5 mg)
Misinterpretation
Misread as 5 mg
Intended Meaning
0.5 mg
Preferred SAFER
Practice!
Always use zero
before a decimal
when the dose is
less than a whole
unit.
“Lead…”
“…don’t follow!”
Zero after
medication decimal
point (e.g., 1.0)
Misread as 10 mg if
the decimal point is
not seen.
1 mg
Do not use terminal
zeroes for drug doses
expressed in whole
27
numbers.
Medication Error Prevention…What YOU can do!
Avoid problem-prone abbreviations or dosage expressions:
These abbreviations must always be clarified before carrying
them out, except in emergencies.
Error-prone…
DON’T Use!
Misinterpretation
Intended Meaning
Preferred SAFER
Practice!
U or u
Misread as zero (0)
or a four (4),
causing serious
overdoses
Unit
“Unit” has no
acceptable
abbreviation.
Write out “Unit”
IU
Misread as IV
(intravenous)
International Unit
Write out
“International Unit”
28
Medication Error Prevention…What YOU can do!
Avoid problem-prone abbreviations or dosage expressions:
These abbreviations must always be clarified before carrying
them out, except in emergencies.
Error-prone…
DON’T Use!
Misinterpretation
Intended Meaning
Preferred SAFER
Practice!
QOD
Mistaken as QID,
especially if the
period after the “q”
or the tail of the “q”
is misunderstood as
an “I”.
Every Other Day
Write out
“Every Other Day”
q.d. or QD
Mistaken as QID,
especially if the
period after the “q”
or the tail of the “q”
is misunderstood as
an “I”.
Daily or Every Day
Write out “Daily”
29
Medication Error Prevention…What YOU can do!
Avoid problem-prone abbreviations or dosage expressions:
These abbreviations must always be clarified before carrying
them out, except in emergencies.
Error-prone…
DON’T Use!
Misinterpretation
Intended Meaning
Preferred SAFER
Practice!
MS and MSO4
Misread as
magnesium sulfate
Morphine or
Morphine Sulfate
Write out “Morphine”
or
“Morphine sulfate”
MgSO4
Misread as
Morphine sulfate
Magnesium sulfate
Write out
“Magnesium sulfate”
30
Examples…
Leading decimal points…lead to errors!!
After receiving an overdose for several weeks, the patient was
admitted to the hospital for hyperthyroidism and weight loss.
The error was recognized during a medical history when the patient
showed a physician the prescription container label.
SAFER!: Lead with 0 when dosage is less than a whole unit, e.g., 0.1
31
Examples…
Missing the point entirely!
A line may interfere with the observation of a decimal point. The order for
20.4 mg of Cisplatin (chemotherapy) was interpreted as 204 mg, resulting
in a ten fold overdose and death.
SAFER!...Make sure the decimal point is OBVIOUS!
32
Examples…
“U” is easily mistaken for “4” or “0”
An accident waiting (impatiently) to happen!!
60 units of insulin were given, not 6!!
SAFER!...WRITE OUT “UNITS”
33
Examples…
“QOD” has been written poorly,
misinterpreted as QID or QD.
SAFER!...WRITE OUT “Every Other Day”
34
Examples…
“QD”?? “Q6”??
SAFER!...WRITE OUT “Daily”
35
Medication Error Prevention…What YOU can do!
Avoid problem-prone abbreviations or dosage expressions:
These three abbreviations require clarification only when
they are unclear (i.e., not always).
Error-prone…
DON’T Use!
Misinterpretation
Intended Meaning
Preferred SAFER
Practice!
@
Misread as 0 (zero),
causing 10-fold
overdoses
at
Write out “at”
ug or µg
Misread as mg
(milligrams), a 1,000
fold difference
micrograms
Use “mcg”
cc
Misread as U (units)
or a zero or zeroes
when poorly written
Cubic centimeter,
i.e., same as
milliliter
Use “ml” or “mL” for
milliliters
36
Examples…
What’s wrong with this picture?
Read the label! Manufacturers often use similarly appearing
label formats on several products (fonts, colors, etc.)
(enalaprilat is for high blood pressure…pancuronium is a paralyzing agent!!)
37
Management and Reporting
• Whether preventable or not, the medication event
must be managed and reported.
• The purpose of reporting is to guide medication
system improvement.
38
Medication safety event management consists of:
• Providing care to the patient.
• Notifying the physician.
• Reporting the event to Pharmacy, via a QVR,
verbally, or otherwise, as appropriate.
39
Management and Reporting
Reporting consists of:
• Completing a QVR for harmful events.
• Also use the QVR whenever a written account of a
harmless event is needed.
• Tell your pharmacist…or utilize the Medication Safety
Reporting Hotline (788-DRUG* or 858-499-DRUG) to
verbally report harmless errors or conditions that may lead
to errors.
• Dialing 9 is not necessary to call 788-DRUG from within Sharp facilities.
NOTE: This is a NEW number as of March 2007
40
If you remember nothing else…
TJC National Patient Safety Goals…
• Avoid error-prone abbreviations,
• Discourage verbal and telephone orders (VO/TO’s)
• Read back any VO/TO’s and critical results,
• Use TWO patient identifiers (not the room number)
• Reconcile medications upon admission, transfer, and discharge
41
If you remember nothing else…
• Never assume anything…when in doubt, ask for help!
• Double- check, insulins, opioids, heparin, warfarin, chemotherapy
• Morphine is NOT HYDROmorphone!
• morphine 5 mg IV = HYDROmorphone 1 mg!! (very potent)
• Report conditions which could lead to medication errors…
….before they happen!
42
Exit
Click the Take Test button on the left side of the
screen when you are ready to complete the
requirements for this course.
Choose the My Records button to view your
transcript.
Select Exit to close the Student Interface.
43