Dr.Sandeep Chatrath, 1 Apollo Hospitals, Regional CEO (AP & Telangana ). L. Ravi, B.Yerni Kumar
Patient’s safety is the first to none. Approximately 3.1 million people have injured annually across the world because of “Medication Errors”. It is estimated that 40 percent of Hospital related errors are due to Medication errors.
Reducing medication errors and developing patient safety has become a common topic of discussion across the federal and state legislators, pharmaceutical companies, the insurance industry, among healthcare professionals, and patients. This is the big news to clinical pharmacologists.
Improving the judicious use of medications and minimising adverse drug reactions have always been key areas of research and study in clinical pharmacology. However, in addition to the older terms of adverse drug reactions and rational therapeutics, now the politically correct expression of medication error has arisen. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). An error can be prevented hence drawn attention to “prevention”.
What can be done to minimise the medical mistakes and improve patient safety?.
The one that seems to be most relevant in the context of medication errors is “an act that through ignorance. We should generally focus on “The Five Rights” of healthcare. They are:
- Right patient.
- Right Medication.
- Right Dose
- Right Time
- Right Route
The practice of medicine, nursing, and pharmacy in the hospital setting is very complex. It consists of many steps occur from “pen to the patient”, “from diagnosis to treat” there is a lot to analyse. Implementing safer practices needs developing safer systems. Many errors happen as a result of poor oral or written communications. Enhanced communication skills, better communications among members of the health care team and the patient are necessary. The informed consent process need to be used as a patient safety tool. The patient should be warned about the materials and possible side effects. One should be told about signs and symptoms before the patient is admitted to the emergency department.
Diminishing medication errors is an ongoing process of quality improvement. Faculty systems must be redesigned with automated integrated medication delivery must be instituted for healthcare professionals. They should be adequately trained to use such technological advances. Sloppy handwritten prescriptions should be displaced with computerized physician order entry. Less expensive yet effective change would be writing the drug in plain English rather than continuing using the elitists’ arcane Latin words and shorthand abbreviations that are subjected to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.
Medication error: Examples of Near-miss events.
Case Study – 1:
A patient was advised with T.Clopilet A 75 mg (Clopidogrel+Aspirin) for coronary artery disease, during the process of indenting a typographical mistake took place and the actual order was typed as T.Clopilet 75 mg and this wrong medicine was intended. During the daily activity of checking the drug chart, it was reviewed and interpreted that a biased drug order is present at the patient bedside before administration. Later on, the concerned staff was instructed to check for the drug chart before administering the medication to the patient.
Case Study – 2:
A 52yrs patient on warfarin for the prevention of Atrial fibrillation, with weekly INR monitoring, was discharged with T.warfarin 2 mg along with other medications mentioned in the discharge summary. As this anticoagulant has numerous food-drug interactions, the patient needs to be counselled, and the diet instructions have to be mentioned as like avoid green leafy vegetables, spinach, cabbage, etc. But diet instruction was not referred to in the discharge summary of that patient. In the part of daily activity, i.e., Checking the discharge summary, it was traced out by the Prescription audit team and ensured the diet instructions to be typed.
In this way, the forthcoming adverse effects of warfare were prevented.
Avoiding medication errors –Medication safety:
The beginners should be conscientious about performing the “five rights” of medication Administering every time—right patient (using two identifiers) with right drug & right dosage at the right time through right route should be the primary focus. Some experts have expanded the list to Five Rights as:
- Right reason for the drug
- Right documentation
- Right to refuse medication
- Right evaluation and monitoring
These approaches are used to detect errors, are most likely to be different in research and routine health care, provided with valuable resources. To limit medication errors and minimize the risks of harm, organizations need tools to detect them. Any system can then be able to analyse errors and identify opportunities for quality improvement. The major methods for detecting adverse events are chart review, incident reporting, computerized monitoring, and searching claims data. Medication errors are largely detected by means of direct observation, voluntary reports prepared by doctors, pharmacists, nurses, patients and chart review.
Review of Medication Chart:
Medication Chart review is retrospective and based on practice sources (medical charts and laboratory data, prescription data, and administrative data. It can be improved by using electronic data, such as electronic health records, computerized physician order entry (CPOE), and computer-integrated triggers. Chart review is the most precise procedure to detect unfavourable events but is less good at detecting medication errors. Cases are assessed independently by two or more experts. Proper planning is needed for definitions, inclusion criteria, and triggers. The downsides of this process are the difficulty in training reviewers ( pharmacists, nurses, students, research assistants) and the resources needed, both economic and human.
Pharmacists identify order errors, rectify them, and fill out a report. Medication errors can thus be prevented before adverse events occur. If CPOE is used, prescription and dispensing errors may be readily detected. Advanced software implementation supports the integration of laboratory and clinical data with Clinical Decision Support Systems (CDSS), rendering detection and prevention of adverse events. CPOE systems enhance safety but need to be used in combination with CDSS. Implementation of information technology is costly and essential for safety, but it can also give rise to new, unknown risks.
Reporting Adverse Drug Reaction (ADR):
At the final strategy, Management in each health care organisation shall encourage reporting of all the medication related error whether it is near miss or adverse drug reaction. It is important that Organisation shall lay down policy for reporting of all adverse drug reaction and employee discovering the ADR shall report it immediately to the prescribing doctor and then complete an ADR report and sent it to the appropriate medical authority for its analysis. It is also important that Drugs and Therapeutic committee of that organisation
Shall actively involve support action taken for each report.
Direct observation is the only means available for detecting errors of administration of medications. A trained nurse recognizes drug administration, records each action and then matches what was done with the original physician orders. The observer must be trained and visits different units in sequence.
IMPRESS STOCK / CRASH CART:
- All Impress stock and Crash Carts are available in all patient care areas
- The Pharmacist checks all the Impress stock and Crash Carts once in a month and the medicines that are near expiry date (before three months of expiry) shall be replaced, and the cart shall be sealed.
- Impress stock were maintained to prevent the delay of STAT doses
- Crash Cart were maintained for the easy accessibility of Medications in emergency conditions like Cardiac arrest
Prevention of medication errors depends on epidemiological knowledge, detection of errors, and improvements in performance. Chart review is the gold standard in detecting adverse drug-related events and, in future, automated monitoring will be the means of capturing adverse events before they occur. Reporting discloses medication errors, can trigger warnings and encourages the diffusion of a culture of safe practice. The audit is a relatively simple tool for evaluating actual performance and in planning corrective actions to reduce the risk of medication errors.
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- Institute of Medicine of the National Academies. Preventing Medication Errors. Quality Chasm Series. Washington DC: The National Academies Press; 2007.