Hi, so welcome to week ten of pharmacology, and
in this week we're gonna talk about Medication Errors.
So this is a star, star, star, star class for sure.
So in this class we're gonna discuss what is a medication error.
We're gonna discuss also what causes medication errors, and
the whole goal is because if you understand what causes medication errors,
then we can try to prevent them from happening.
So a medication error is different from a documentation error.
So last week we talked about a documentation
error ,which was an error where you just made a spelling mistake or
you recorded the medication in the wrong spot in the documentation.
An actual medication error is when the wrong drug is prescribed,
the wrong drug is given, or the wrong dosage is given, or
the wrong protocol for administering the drug is used.
So it's given by the wrong route or etc.
So this is were there's actually a problem with
the type and amount of medication that a person receives.
So this is quite a lot more serious.
It also has to be documented, but
there are some other things that you must do as well.
So just so that know, medication errors are fairly
unnervingly common in North America, including Canada.
So some of the first studies to look at this were in 1999.
And there was a study in the US called, To Err is Human.
And they discovered that between 44 to 55,000 people in the US
were killed every year by medication errors.
And at that time it was the fourth leading cause of death in North of America.
In Canada it's also very serious.
It's the most common cause of injury and
preventable death that occurs within hospitals.
About one and five nurses in hospital settings, this was in 2013,
reported that they made a medication error, either occasionally or
frequently during the past year.
Medication errors affect at least 1.5 million Canadians every year.
So one in ten patients receives the wrong drug or
the wrong dose while they're in a hospital.
The frequency of medication errors varies across the world.
Australia seems to be the worst place to get a prescription medicine where their
medication error is around 17%.
Ottawa in 2012 was around 13% in terms of medication errors.
So a 2013 study of Ontario hospital, so
this was the first year where there was mandatory reporting of medication errors.
And they found 36 adverse events, so where there was an injury that occurred,
and that included ten deaths, and that was due to medication errors.
And this was, as I said 2013 was the very first year where there was
mandatory reporting of medication errors.
This little chart here also shows you,
in terms of different types of activities,
and in terms of what are dangerous activities.
And certainly being in the hospital is one
of the most dangerous places in terms of losing your life.
The ISMP, or the Institute for
Safe Medication Practices is an international organization that looks at
trying to improve the safety of medications administration.
And there is a Canadian contingency, a Canadian organization, so ISMP Canada.
They are independent from the government, they are non-profit,
and they collect and they analyse medication error report.
And so they were some of the first studies on medication errors in Canada,
came through the ISMP, and they make recommendations for increasing safety.
So they look at the causes of medication errors, and then they try to find
solutions to them, whether that's through the pharmaceutical companies, or
through education of health professionals, or data that they have to collect.
So they work really hard to try to increase medication safety.
So a lot of the things that we're gonna discuss about
improving your safe administration medication, come through the ISMP.
They collect reporting of errors on a voluntary basis,
and in some places in the country,
that's the only place where errors are reported, is on voluntary basis.
This has its advantages, in that because it's voluntarily and
it's non-punitive, meaning that a person couldn't be punished for
reporting a medication error, that allows more errors to be reported.
And the ISMPs view is that the more people that report errors, the more
often that we can discover what the cause is, and then we can work to correct it.
Because often it's not that an individual wants to make an error,
it's that there is some sort of common cause, and underlying that.
So for example, medications look-alike, or
certain abbreviations seem to cause errors in many different places,
and if nobody reports them, then we can't fix that problem.
So that's their idea.
And they have a way to report those errors,
and you should take a look at their website.
There's a link up in Blackboard, and it's ismp-canada.org.
So they also report not only just if an error has occurred, but also a near miss.
So for example, if you almost made an error but caught yourself, again,
that's important to report to the ISMP.
Again, because somebody else may not have caught that error, and
there's something common that we can fix.
It's entirely confidential, non-punitive, and
you can also report if you feel like a situation is unsafe.
Just on that last slide, the ISMP also just very recently in 2014,
had a voluntary summit in Toronto, and they want to devise a national
medication safety plan, and so that's pretty exciting too.
If we can have something that is Canada wide, and recommends best practices.
So if we look at the literature to find out where medication errors occur,
they can occur in many different places.
So if you think about how a medication gets to a particular individual,
it starts right with the research and the pharmaceutical company, and
their data that they collect.
And then that of course goes to Health Canada and their approval process, and
then that then goes to the physicians, and
their ability to prescribe that medication appropriately.
And then to the pharmacist, and then to the person that's going to administer
the medication, and then finally to the individual.
So there are lots of places along that chain where something can happen.
So again, if we look at the data, about 19% of medication errors
occur in the prescribing phase, so from the physician.
About 19% of errors occur in the preparing or dispensing phase, so the pharmacist.
And then about 50% of the errors occur in the administration phase, so
that includes things like transcribing information as we've been doing, right?
Transcribing information from the medication order onto an MAR sheet,
or passing on instructions right down to the actual administration process.
So of course we should be concerned about this 50% because
that is the part that DSWs are involved in.
So we gonna go through some of the common causes of medication errors.
And as we go through this,
I'd like you to ask yourself what do you do as a DSW to help prevent this error.
And one of the biggest things that we're gonna come back to again and again and
again, is that if you are unsure,
if you have any doubts at all about what you should be doing.
Whether it's whether you can read the order or not, or whether there's red flags
that appear in your head, then you always need to double-check.
And if that means contacting a pharmacist or a physician to just double-check,
to make sure that you are administering it, or
having somebody else check over your work, having a second set of eyes, then do it.
So always be on the safe side.
So a really big area, and it's particularly in the past, and less so
now that we have computers.
But a big factor in making medication errors is poor handwriting, and
if a physician writes an order that the pharmacist or a DSW or
a health professional can't read, then that's very tricky.
So I've got a couple examples here.
So this top one here says, and see if you can read this,
Lasix and
then this part here milligrams by mouth today.
And the problem was that when the physician wrote this medication order,
he or she started to write 100 mg and then changed his or
her mind, and then changed the 1 into a 2, okay?
So what this order should say is Lasix 200 mgs by mouth today.
However, because that looks almost like there's a 1 and a 2 together,
then the medication error that was made was that the person received
1,200 mg by mouth today instead of 200 mg.
The second one also is a handwriting issue.
That says Lovenox.
And Lovenox is an anticoagulant.
And I believe this says
4cc subcutaneous qd every day.
I think that's what that says, although this is also dubious.
The medication error that was actually made
was that this drug Lovenox was confused with this drug up here, Lasix.
And so the person received Lasix, which is a diuretic, which is given for
things like high blood pressure, instead of getting their anticoagulant, Lovenox.
So they got the wrong drug.
So what do you do as a DSW to prevent that?
Okay, star, star, star.
So this is another common medication area
that's caused by a problem with communication.
And in this case it's how numbers and zeros and decimal points are used.
And we've talked about one of the things that we can do which is always write
a number 1 as O-N-E, right?
So because 1 can look and l, it can look like a t,
it can look like a 1, and that can be confusing.
Along those lines, the number 7, also can look like a 1, as well.
And so it's recommended instead of just writing 7 just normal,
you put a line through it.
And that indicates a 7, and then that helps distinguish it from a 1.
A really important thing that we discussed earlier in the year was the use of
zeros and decimal points.
So, for example, if you look in this top border,
this was an actual medication error that was made.
And this actually says 2.0 mg by mouth.
But because the zero followed the decimal point, and we lost
the decimal point in the lined paper, this person was given 20 mg instead of 2 mg.
So the rule is that never use a zero by itself after a decimal point.
In the bottom order, this was another medication error.
So Terbutaline, and it says 0.5 mg now, subcutaneous.
And of course, this decimal point was lost also, so
the person received 5 mg instead of 0.5 mg.
And again they received the wrong dose.
So always put a zero before a decimal point, so
that we know that the decimal point is there.
Sometimes there can be confusion between different units, and
here's a couple of examples of where this can happen.
So in the left-hand side you see this cup, and
this cup actually has different units on different sides of the cup.
And on this side of the cup it's says DRAMS.
And on the other side, it would say, mL.
And in this particular case, the person was suppose to receive five mills but
instead they received five drams of this liquid so, and
it was a nurse that actually measured five drams.
And five drams is equivalent to about 18.5 mL, so again the person
received much more medication than what they were suppose to receive.
In the right-hand side is a similar case.
This actually was a father that bought medication,
just Acetaminophen over-the-counter, and
the dosage as written on the package was 12.5 milligrams.
But then when you look over here on the dosing cup, this says 12.5 mL.
And so the father actually filled the cup up to 12.5 mL, and
was ready to give that to his son.
But the amount of the drug that's contained in 12.5 mL is 31 milligrams.
So again, if the dosing written on the packaging is in milligrams and
then the cup is measured in mL, then that can create that type of error.
Now that was a near miss, so the father caught that mistake and then reported it.
And since then, the packaging has to be quite a lot clearer in terms of how
the dosage is reported, and
it should match with the little cup that comes with the medication.
Another thing that can cause a problem with communicating orders is using
inappropriate abbreviations, and we've touched on this already.
In the top one, other than just being horrible handwriting as well,
the big mistake came with this, is that this says M-O-R-P-H, so morph, okay?
And they used an abbreviation for a drug.
Instead of saying morphine, they just wrote, morph.
And this person actually received hydromorphone,
which is quite a lot stronger than morphone, and so
when they received it at that dosage, it actually caused a fatal event.
So the rule is never, ever, ever, ever abbreviate a drug name.
The drug name has to be written out in full,
and preferably also with both generic and brand names.
Because that gives an opportunity to double-check whether or
not you've got the right drug.
The second one, the order is supposed to say run @, so this was an IV,
run @ 5 ml/hour, but this abbreviation for
at, okay, at which we shouldn't use, looks like a 2.
And so this person received, instead of receiving an infusion at 5 ml/hour,
they received an infusion at 25 ml/hour.
And the last one I think we've looked at already.
Again, this is an abbreviation for units, and so
it's supposed to say 6U, 6 units, Regular Insulin Now.
And instead they received 60, because the U is mistaken for a zero.
And, again, that was a fatal event.
So the ISMP has made a list of abbreviations that we should avoid.
And we've been talking about them and here's a list.
So units and international units should be written out in full.
QD or QOD, so daily or every other day again written out.
Same with right eye, left eye, both eyes.
D/C is discontinue, and that's okay.
But if you wanna write discharge, you're supposed to write that out entirely.
Instead of using a unit of ccs, we should be using mL.
The microgram, @, >,< shouldn't be used cuz they can be mistaken for
a number, and then any abbreviation for a drug.
Sometimes the intent of the drug or the root of the drug is mistaken.
And I think we talked about this.
This was not a fatal event, although it didn't help their ear infection.
This says 2 drops Garasone in R ear, so right ear.
Of course that's not the right abbreviation for a right
ear, and so it was confused as to how that drug was supposed to be administered,
so they ended up giving drops rectally, so in the rear.
And the last one is important as well.
And that is verbal orders.
So these are orders that are given over the phone.
And as a rule, DSWs should not receive verbal orders.
So somebody cannot phone you up and give you a medication order over the phone.
So it should be in writing for DSWs.
And part of the reason is, is there's a protocol, and
here's an example of where a medication error was made.
So somebody said over the phone, two 50 mg indomethacin suppositories, okay?
And of course,
what they heard over the phone was 250 mg indomethacin suppositories.
And so the person received 250 mg instead of two, 50 mg suppositories.
And so they received, again,
a greater amount of that medication than what they were supposed to receive.
Okay, so this'll be the end of part one.
And we'll pick up here where we left off in part two.