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Introduction

The Institute of Medicine reported that in the US:

• 9000 deaths occur yearly due to medication errors.
• Medication errors account for :
➢ One out of 131 outpatient deaths.
➢ One out of 854 inpatient deaths.

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 Introduction
Deaths from
Medication Errors

1983 1998

Phillips DP. Annu Rev Public Health. 2002;23:135-50. 6

The BMJ, May 3, 2016

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Which patients are most at risk of medication
error?
• Patients on multiple medications.
• Patients with another condition, e.g.
renal impairment, pregnancy.
• Patients who cannot communicate well
(e.g. different language, deaf etc.).
• Patients who have more than one
doctor.
• Children and babies (dose calculations
required).

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 Medication Errors in Pediatric Patients

➢ As many as 1 in 10 hospitalized children

are impacted by a medication error.
➢ Up to 35% of these errors are serious or
life threatening.
➢ Three times more likely than adults to
experience harm from medication errors
and adverse drug events.

Results of Survey on Pediatric Medication Safety. ISMP. 2015

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 What is a Medication Error?
➢ The National Coordinating Council for Medication
Error Reporting and Prevention defines a
Medication error* as follows:

“ Any preventable event that may cause or lead to

inappropriate (wrong) medication use or patient
harm while the medication is in the control of the
health care professional or a patient. ”

What is the difference between the Medical error and Medication Error?
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What is a Near miss?
➢A near miss is an event or situation
that could have resulted in
medication error, but did not cause
harm, either by chance or through
timely intervention.
➢It is also referred to as a “close call”.
➢Near misses if ignored may lead to
medication errors.

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 Examples of Medication Errors
Error Example
Prescribing error Incorrect drug, dose, route, or formulation, including contraindication
due to allergy.
Omission error Missed dose.
Wrong time error Not administered within dosing time.
Unauthorized drug error Drug administered not prescribed.
Improper dose error Dose administered not prescribed.
Wrong dosage form error Dosage form administered not prescribed.
Wrong drug preparation error Drug preparation or compounding error.
Wrong administration technique Route or rate different from prescribed or recommended.
Deteriorated drug error Expired or deteriorated drug administered.
Monitoring error Appropriate drug monitoring not completed.
Compliance error Patient adherence incorrect.

Source: American Society of Hospital Pharmacists. ASHP guidelines on preventing medication errors in hospitals. 14
 Medication
errors
classification

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Medication errors classification
Medication errors can be classified in a
variety of ways as the following:

A. Classify them by their impact on

patient (or severity).
B. Classify according to where they
exist within the medication use
process.
C. Classify based on a Psychological
approach.
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A. Classify them by their
impact on patient
(or severity)

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 Classification of Medication errors According to
the severity
➢ When an error occurs, there is not always an adverse outcome.
➢ It is important for hospitals to monitor both the types of errors that
occur and the outcomes associated with them.
➢ The NCC MERP* developed a medication error index that serves to
categorize errors based on the severity or outcome of the error.
➢ This index is divided into 4 main categories and 9 subcategories as
follows:
Main Categories No error Error, no harm Error, harm Error, death
Subcategories A B, C, D E, F, G, H I

* NCC MERP: The National Coordinating Council for Medication Error Reporting and Prevention 18
 Classification of Medication errors According to the
severity…..Cont’d
Error Error Reached Associated Necessary measures
category occurrence patient harm
Remove hazard
A Potential No No (circumstances or events have the capacity to cause error).

Document and educate staff

B Yes No No
(error didn’t reach the patient→ near miss).
Document error and educate staff. Monitor
C Yes Yes No patient for delayed effects
(e.g. Multivitamin was not ordered on admission).
Immediate monitoring and intervention
D Yes Yes No (e.g Regular release metoprolol was ordered for patient
instead of extended-release).
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 Classification of Medication errors According to the
severity…..Cont’d
Error Error Reached Associated Necessary measures
category occurrence patient harm

Medical intervention (e.g. Blood pressure medication was

E Yes Yes Temporary
mistakably absent from the orders )
Hospitalization or prolonging hospital stay
F Yes Yes Temporary (e.g. Anticoagulant, such as warfarin, was ordered daily when
the patient takes it every other day)
Variable (e.g. Immunosuppressant medication was by mistake
G Yes Yes Permanent
ordered at one-fourth the dose)
Vital support intervention (e.g. Anticonvulsant therapy was
H Yes Yes Risk of Death
mistakably absent)
(e.g. Myocardial infarction as result of beta-blocker was not
I Yes Yes Death reordered)

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B. Classify according to where
they exist within the
medication use process

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Classify according to where they exist within the
medication use process
Prescribing
- Wrong drug. - Wrong dose.
- Wrong patient. - Wrong form or route of administration.

Transcribing and interpretation

- Illegible handwriting -Misinterpretation (e.g. misreading abbreviations).

Dispensing and Preparation

- Wrong patient or drug. - Error in drug utilization review.
- Error in preparation or calculation.

Administration and Monitoring

- Wrong drug, dose, route, administration time , infusion rate. - Missed dose.
-Incorrect handling or storage. - Failure to monitor for therapeutic and adverse effects.
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Medication Errors in the medication use process

✓ A study identified the frequency of occurrence of error

at each stage of the hospital medication use process:
• Prescribing 39%.
• Order transcription 12%.
• Dispensing 11%.
• Administration 38%.

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 C. The classification of
medication errors based on a
Psychological approach

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 The classification of medication errors based on a
Psychological approach

Errors

Mistakes Skill based errors (slips and lapses)

Errors in planning actions Errors in executing correctly-planned actions

3. Action-based errors
1. Knowledge based 2. Rule-based errors 4. Memory-based
(slips)
Errors errors (lapses)
2a. Good rules not 3a. Technical errors
applied or 2b. Bad rules
misapplied

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 The classification of medication errors based on
a Psychological approach
Type of error Examples
Mistakes Giving penicillin, without having established whether
Knowledge-based the patient is allergic.
Rule-base A nurse routinely shakes all liquid medications before
o Mistakenly applying a good rule use. This is a good practice for suspensions but wrong
for insulin, as shaking it damages the proteins.
o Applying a bad rule Using excessive doses of captopril to lower BP

Skill-based errors Selecting hydralazine instead of hydroxyzine due to

Action-based (slips) similar names, causing unintended vasodilation.
Memory-based (lapses) A doctor forgets to stop heparin before surgery,
leading to excessive bleeding.

Robin E. Ferner, Drug Safety 2006; 29 31

Preventing errors by Psychological
approach classification
Knowledge-Based Errors
Prevention: Improve knowledge and provide decision support

✓ Implement computerized clinical decision support systems (CDSS)

✓ Provide drug interaction alerts and dosing calculators
✓ Offer ongoing education and training programs

Rule-Based Errors
Prevention: Standardize and clarify protocols

✓ Develop clear, evidence-based clinical protocols

✓ Regularly update guidelines to reflect current best practices
✓ Provide scenario-based training on when exceptions apply

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Preventing errors by Psychological
approach classification
Skill-Based Errors
Prevention: Reduce distractions and standardize processes

✓ Minimize interruptions during medication preparation and administration

✓ Implement standardized medication administration workflows
✓ Ensure adequate staffing to prevent fatigue
✓ Schedule regular breaks to manage exhaustion

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 The factors
contributing to
medication errors in
the hospitals

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The factors contributing to medication errors in
the hospitals
Many factors can lead to medication error:

1. Factors associated with health care

professionals.
2. Factors associated with patients.
3. Factors associated with the work environment.
4. Factors associated with medicines.
5. Factors associated with computerized
information systems.

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The factors contributing to medication errors in the hospitals…Cont’d
1. Factors associated with health care professionals

• Lack of therapeutic training.

• Inadequate drug knowledge and
experience.
• Poor communication between
health care professional and
with patients.
• Inadequate awareness of risk.
• Overworked health care
professionals.
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The factors contributing to medication errors in the hospitals…Cont’d
2. Factors associated with patients

• Patient characteristics (e.g.,

personality, education and
language barriers).
• Complexity of clinical case,
including multiple health
conditions, multiple medications.

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The factors contributing to medication errors in the hospitals…Cont’d
3. Factors associated with the work environment

• Insufficient resources.
• Issues with the physical work
environment (e.g., lighting,
temperature and ventilation).
• Time pressures and workload.
• Lack of standardized protocols
and procedures.

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The factors contributing to medication errors in the hospitals…Cont’d
4. Factors associated with medicines

• Look alike sound alike.

• Labelling and packaging.
• Medication storage.

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The factors contributing to medication errors in the hospitals…Cont’d
5. Factors associated with computerized information systems

• Difficult processes for generating first prescriptions

(e.g. drug pick lists, default dose regimens and
missed alerts).
• Difficult processes for generating correct repeat
prescriptions.
• Lack of accuracy of patient records.
• Poor design that allows for human error.
• Poor integration between the hospital systems.
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Detecting Medication Errors
Importance

➢ Measuring Medication Errors is an important tool for:

• Identifying and reducing the preventable risks
associated with the medication-use process.
• Assessing the impact of system improvement.

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Detecting Medication Errors…..cont

➢ Reported medication error rates are simply a

measure of the ability of the organization to
recognize and report medication-related problems.
➢ So, a hospital with a large number of error reports
may actually have a lower true underlying
medication error rate than an organization where
few reports are received, analyzed, and acted on.

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Medication Error Detection Methods…..Cont’d
1. Voluntary reporting and incident reports

➢ A voluntary reporting system (paper, telephonic, or online).

➢ The most common method of identification of errors and events.
➢ Anyone detecting or committing an error can report it without associating their
name with the error.

Weaknesses:
Strengths:
• The likelihood of having an error
reported is dependent on staff
• Cover all phases of the
recognizing error, numerous
medication use process.
barriers to reporting (e.g. time,
• Low cost.
perceived negative consequences).

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Medication Error Reporting System (No HARMe)

[Link]
services/medication-error-reporting-system-no-harme/

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Medication Error Detection Methods…..Cont’d
2. Direct-Observation method

➢ The direct-observation method uses trained observers to watch the real-time

administration of medications.
➢ Notes from the observations are compared with prescriber's orders to
determine if an error has occurred.

Weaknesses:
Strengths: • Costly.
• Time consuming.
• Consistent and
• Limited to the identification
standardized.
of errors that occur during
• Has greatest capture of
the administration phase of
events.
the medication use process.

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 Medication Error Detection Methods…..Cont’d
3. Chart review

✓ In this method we review the patient charts looking

for particular cues (signal) or data elements that
signify an error or event has occurred.

Strengths: Weaknesses:
• Looks at medication use • Limited to accuracy and
in the case of individual completeness of medical
patient.
record documentation.

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 Medication Error Detection Methods…..Cont’d
4. Computerized methods

➢ It is an improved chart review method that uses automated

systems to identify alerts or triggers that have been shown to
efficiently identify patients with potential ADEs.
➢ The triggers are cues that a patient may have experienced an
error and/or adverse event.
➢ Example triggers include the use of antidote agents (e.g.,
flumazenil, naloxone, phytonadione) or abnormal values for labs.
Strengths: Weaknesses:
• Low cost. • High rate of false
positives.
• May catch potential problems
• Details on causes may
before harm to patient. not be captured.

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 General
recommendations to
prevent medication
errors

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 General recommendations to prevent medication errors

Reduce dependence on memory

• Use computerised order entry.
• Use drug-drug interaction checking systems.
• Use bar-coding on drugs, containers, medication
records, patient wristbands.
• Use computerised patient information.
Simplify
• Limit choices of available drugs in pharmacy.
• Limit dosage strengths and concentrations for each
drug.
• Mix intravenous medication in the pharmacy.
Medication safety Practice guidelines and tools, Singapore 51
 General recommendations to prevent
medication errors…..Cont’d
Standardise
• No error-prone abbreviations (e.g. Use “units” not “u”, etc.).
• Use generic names.
• Use protocols for High alert medication (HAM) medication
administration (heparin, insulin, chemotherapy).
• Standardise times of drug administration.
• Store medications in the same place in every medication
room.
• Use standard equipment (e.g. one kind of pump or syringe).

Medication safety Practice guidelines and tools, Singapore 52

 General recommendations to prevent medication
errors Cont’d
Differentiate: Eliminate Look-Alikes and
Sound-Alikes
• Store similar-looking medications in separate
places.
• Repackage or re-label look-alikes to
differentiate them.
• Alert staff and post information on
medications with similar names (including
sound-alike).
• Use striking caution stickers on stock
containers to alert staff to look-alikes.

Medication safety Practice guidelines and tools, Singapore 53

 Case Report
➢ A 38-year-old woman comes to the hospital with 20
minutes of itchy red rash and facial swelling; she has a
history of serious allergic reactions.
➢ A nurse draws up 10 mls of Adrenaline (epinephrine)
into a 10 ml syringe (1 mg in total) and leaves it at the
bedside ready to use just in case the doctor requests it.
➢ Meanwhile the doctor inserts an IV cannula.
➢ The doctor sees the 10 ml syringe of clear fluid that
the nurse has drawn up and assumes it is normal
saline.
 Case Report
➢ There is no communication between the doctor and the
nurse at this time.
➢ The doctor gives all 10 mls of adrenaline (epinephrine)
through the intravenous cannula thinking he is using saline
to flush the line.
➢ The patient suddenly feels terrible, anxious, becomes
tachycardic and then becomes unconscious with no pulse.
➢ She is discovered to be in ventricular tachycardia, is
resuscitated and fortunately makes a good recovery.
➢ Recommended dose of adrenaline (epinephrine) in
anaphylaxis is 0.3 - 0.5 mg IM, this patient received 1mg IV.
 Case Report

1-Can you identify the contributing factors to this error?

➢ Lack of communication.
➢ Inadequate labeling of syringe.
➢ Giving a substance without checking and double
checking what it is.
➢ Lack of care with a potent medication.
 Case Report

2. How to avoid this mistake in the future?

➢Ensure a good communication between the nurse and the
health care professional.
➢Double checking the name of medication before
administration.
➢Label the syringe.
 Case Report
3. According to medication error severity classification,
what is its category?
➢Category H
➢Error contributed to a
temporary harm to the patient
and required intervention
necessary to sustain life.
 Case Report
4. Classify according to where they exist within the
medication use process
➢During the administration step.
Thank you

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