WHAT IS A MEDICATION ERROR?
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professionals, patients or consumer.
WHAT ARE THE VARIOUS CAUSES OF SUCH ERRORS?
1.Patient information9allergies,age,weight) is missing.
-Drug information (dosage,frequency, dose) is missing.
2.Miscommunication of drug order
-Illegible, incomplete, mis-heard etc.
Drug name, label, packaging problem especially in case of look/sound alike drugs
-Workflow lighting, noise, interruptions etc
-lack of staff education
3.Pharmacist and physician knowledge is lacking
TYPES OF MEDICATION ERRORS:-
REASONS FOR THESE TYPES OF ERRORS:-
1. Prescribing Errors:- Illegible handwriting- one of the most common reason
-Dose, frequency, route of administration of the drug not mentioned.
-Allergies not mentioned
-Prescriptions are not written in capitals
-SOS orders are not mentioned.
eg;-Dose of Tab.Ceftum is 500mg. But in prescription it is written as 400mg.
2. Transcription Errors:-Mainly indenting errors like wrong drug/ strength/ dose/ route/ frequency.
eg;-Inj.Fortwin was transcribed instead of Inj.Fortum
3. Dispensing Errors:- due to selection of the wrong strength/ product/ wrong patient/ wrong dose.
-Mainly caused when two or more drugs have a similar appearance/ similar name:-
(eg;- LASA drugs)
Eg;- Inj.Kenadion was transcribed but Inj.Ketoral was dispensed.
4. Administration Errors:- Occurs when a discrepancy between the drug therapy received by a patient and the drug therapy intended by the prescriber.
Eg;- Improper dose, wrong patient, wrong strength, wrong frequency, wrong duration etc.
HOW TO MINIMIZE THESE ERRORS:-
To minimize prescription errors;-
-Ensure knowledge of drug before prescribing
-Mention the drug name & patient details clearly on the prescription.
-Ensure that an accurate drug history is taken
-Include all details of the drug therapy like dosage, duration of treatment etc.
To minimize administration errors;-
-Check patient’s identity (Name & UHID number only)
-Update knowledge about medications
-Don’t guess! Always seek for clarifications
-Minimize interruptions during ward rounds.
-Confirm all of the 6 ‘R’s (Rights) prior to administering a medication.(Right patient/ Right drug/ Right dose/ Right dosage form/ Right route/ Right time/ Right documentation)
WHO SHOULD REPORT MEDICATION ERRORS
Any of the health care professionals like physicians, clinical pharmacists, nurses and at times even the consumer.
WHO TRACKS MEDICATION ERRORS?
-Prescription Audit Team
-Reviewed by Pharmacologist & DMS
To err is human and we all make errors from time to time. As we have seen, there are different types of medication errors possible and we should take steps to minimize them. The essential components of this are monitoring for and identifying these various errors, reporting them, analysing the root causes and changing procedures accordingly.