Defining Medication Error;
The United States National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as:
“Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”
This definition is broad and suggests that errors are preventable at different levels. Medication error has also been defined as a reduction in the probability of treatment being timely and effective, or an increase in the risk of harm relating to medicines and prescribing compared with generally accepted practice.
The goal of medication therapy is to achieve therapeutic benefit and also improve quality of patient’s life while minimizing risk to patients. Medications are an important aspect of treatment given to almost every patient in the hospital. However, medications are not without risk and occasionally medications can cause harm. Both prescription and nonprescription medication carry the inherent risk of causing adverse drug events even when used at appropriate therapeutic doses and with appropriate monitoring in place. Many medication errors are probably undetected.
Because the clinical significance of many medication errors may be minimal with few or no consequences that adversely affect a patient, many medical errors are probably undetected. Tragically, some medication error result in serious patient’s morbidity or mortality.
Medication errors are not only confined to the hospital setting. Reports from the Medication Defense Union and the Medication Protection Society revealed that 25% and 19% respectively of legal claim against general practitioners are related to medication error. The occurrence of medication errors can compromise patient confidence in the healthcare system and in addition increase healthcare cost. Economics consequences may include the award of damage to the patient, extension of a patient’s stay in hospital and then potential financial support required for long term care of a patient who suffers permanent injury.
Medication error rarely the fault of a single person and are generally multidisciplinary and multifactorial stemming from the complexity of the medication use process which includes five core step: medication prescribing, order processing, dispensing, administration and monitoring. To evaluate the root cause of medication is essential to implementing changes to the medication use system and this can prevent the same error from occurring in future.
Type of Medication Errors
Prescribing errors may be define as an incorrect drug selection for a patient, can be the dose, the strength, the route, the quantity, the indication or the contraindications. The prescriber must specify the information which the pharmacist need to dispense the drug in the correct dosage and form suitable for the individual patient plus the directions the patient needs to administer it safely. A study undertaken in a hospital setting by lesar et al (1997) found an error rate of 4 per 1000 prescription orders. Some prescription error recorded at the University of Cape Coast hospital include illegible hand writing , wrong or absent dosage regimen, prescribing antitussive for children below the age of six and the use of medical abbreviations.
This type of errors occurs at any stage during the dispensing process from receipt of a prescription in the pharmacy through to the supply of a dispensed product to the patient. A recent in the USA has estimated that dispensing error occurs at a rate of 1-24%. This error may undermine the patient’s confidence in the pharmacist.
These error include the selection of a wrong product or strength. This primarily occurs when two or more drugs have a similar appearance or similar name, other examples include dispensing a wrong dose or dispense a medicine to the wrong patient.
In 2013, an overdose of anti-retroviral drugs was dispensed to an HIV positive patient at the University of Cape Coast Hospital pharmacy. These medications were quickly recalled before they could be administered and the right dosage and quantity given back to the patient. There has also been instances where prescribed medications have been dispensed to the wrong patient. For example, a patient was prescribed metronidazole tablets but ibuprofen tablets were dispensed instead. Similarity in these products packaging was identified as the cause. But in all cases patients were recalled and the correct medication dispensed.
Drugs names that may be confused
A drug administration error may be defined as a divergence between the drug therapy received by the patient and the drug therapy intended by the prescriber. Drug administration is associated with one of the highest risk areas in nursing practice. For example, when a vaccine was administered into the gluteal muscle instead of the deltoid or when Paracetamol suppository was accidentally inserted into the vagina of a child instead of the anus. The “five rights” have long been the basis for nurse education on drug administration that is giving the “right dose of the right drug to the right patient at the right time and by the right route.” Drug administration errors largely involve errors of omission where administration is omitted due to a variety of factors e.g. wrong patient, lack of stock, etc. Other types of drug administration errors include wrong administration technique, administration of expired drugs, wrong route, wrong rate, wrong dosage form, and wrong formulation
Monitoring errors occur when appropriate clinical or laboratory investigations are not used to adequately assess patient’s response to prescribed therapy. Examples include errors occurring as a result of the inappropriate monitoring of therapy and/or failure to monitor laboratory data. A high-risk example would be giving warfarin (an anticoagulant) when the patient’s international normalized ratio is found to be significantly elevated, which may result in excessive bleeding or giving an antihypertensive medication without monitoring the patient's blood pressure.
CAUSES AND PREVENTION OF MEDICATION ERRORS
Medication use is a complex process and there are many drug-related challenges at various levels involving healthcare professionals and patients. Although medication errors can occur anywhere in the health care system from prescriber to dispenser to administrator and finally to patients, the simple truth is that many errors are preventable and the causes of these errors should not be seen as problems but rather as sources of information to improve patient safety and quality of care.
Inadequate information and knowledge of a patient have been implicated as a major cause of prescribing errors. In order to avoid prescribing a drug or selecting a dose that could be inappropriate or harmful to a patient, it is important for the prescriber to have access to the patient’s complete health information record at the time the patient is being seen, with information including patient age, weight, diagnosis history, all medications the patient is taking, laboratory test results, list of other physicians the patient has seen, past hospitalizations, past dose-response relationships and drug allergies.
Illegible handwritten prescriptions and orders that are unclear, ambiguous or overly complex can also cause medication errors. A study conducted estimated that one-third of physicians' handwriting was illegible. Prescribers should, therefore, review all medication orders for accuracy, completeness, and legibility immediately after they have been prescribed. This used to be a problem in the 80's, however, in the developing world it isn't so now. Most hospitals in Ghana have moved away from handwritten prescription to computerized physician order entries (CPOE). At the University of Cape Coast hospital, all patient information is stored onto a computer and updated with each visit but prescriptions are still handwritten leaving room for errors. If there is a question about legibility of a handwritten prescription, the pharmacist or nurse should always clarify the order with the prescriber. So the issue of technology in hospital setting could offer some solution to medication errors.
Orders given verbally, rather than in written form, are innately problematic because of different parlances and accents, misinterpretations of names and strengths, etc. Verbal medication orders should be discouraged and utilized only when written or electronic medication orders are not feasible. The key to a safe process is using “read back.” Here, the healthcare personnel should record the order directly onto the prescription pad or order sheet or computer as the prescriber is relaying it, after which the information will be read back to the prescriber. The prescriber should request the read back if it is not offered. During this process, spell the drug name and strength of the medication. For example, errors have been reported when the number 15 has been misinterpreted as 50. Always say “one five” for 15 or “five zero” for 50. At the University Of Cape Coast Hospital such orders are seldom employed.
Interruptions can easily result in medication errors. It is important for all members of the team to eliminate or minimize interrupting a nurse who is preparing a medication or in the process of dispensing or administering a medication. Strategies such as no-distraction zones, “do not disturb” signs over medication preparation areas and use of colored vests worn by health care providers during the medication administration process are examples of methods for alerting colleagues not to interrupt health care providers while they are focused on such tasks. Unfortunately, in our world one thing that interrupts health professionals the most is mobile phone calls. The priority level for such is much higher than most patient needs. A joke is told of a nurse who interrupted an injection being administered to listen to a mobile phone call.
The packaging and labeling of various dosage formulations often contribute to or fail to effectively prevent errors. The lack of safety designs worsens the problem of confusing nomenclature for different dosage formulations. According to the IOM, labeling and packaging issues cause 33% of medication errors including 30% of fatalities from medication errors. At the University Of Cape Coast Hospital some medications dispensed to patients did not bear any label and for those that were labeled the information provided on some of the labels were inadequate for effective administration. Steps that have been put in place to prevent this includes educating staff about the importance of labeling and inspecting all medications before they are dispensed for labeling errors. Labeling and packaging practices that more effectively convey properties and risks of particular dosage forms would help differentiate formulations and would alert caregivers and patients of the proper use of a dose formulation.
Miscommunication amongst health care professionals is a common cause of medication errors. Abudato (2004) states that 90% of errors that occur within the healthcare industry are due to communication break down at the nurse-physician level. A study conducted found that poor communication was responsible for causing between 44,000 and 98,000 patient deaths annually in American hospitals alone. The elimination of communication barriers is a key element to medication error reduction strategies. Moreover, pharmacists may find it difficult to clarify prescriber orders with nurses and nurses may find it challenging to monitor medications dispensed at the pharmacy. In all settings, healthcare professionals who may receive information from clinicians, pharmacists, nurses or even from a patient questioning a prescription order must find ways to make feedback or communication a priority to help increase medication safety. At the University of Cape Coast Hospital, regular interdisciplinary ward rounds and the availability of telephones at all departments also help to prevent miscommunication by allowing for easy feedback between health workers.
Look-alike and sound-alike drug names are a serious problem in healthcare, accounting for 29% of medication dispensing errors. Medication errors involving look-alike and sound-alike drug name mix-up can cause serious patient harm. It is often difficult to detect the error as the dispensed medication is presumed to have been prescribed for the patient. Examples include; Isordil – Plendil, Celebrex –Cerebyx, Lamictal – Lamisil and Zyprexa – Zyrtec – Zantac. Many, if not all, of these drugs with similar names carry different indications for use, therefore recording the indication with the medication order can reduce confusion. Using bold print can also help to clearly distinguish letters which differ on product with look-alike drug names. This strategy is commonly referred to as “tall man lettering,” e.g., chlorPROMAZINE and chlorPROPAMIDE. In 2009, look alike products of magnesium sulphate and metronidazole infusions produced by Intravenous Infusions Limited, Ghana recorded five deaths when magnesium sulphate infusion was mistaken for metronidazole infusion and administered. Two near fatal cases were also recorded at the University Of Cape Coast Hospital that same year. Subsequently, the metronidazole infusion was withdrawn and repackaged.
Medical abbreviations are also a major cause of medication errors. The FDA and ISMP embarked on a joint campaign to eliminate the use of potentially confusing abbreviations, symbols and dose designations in various forms of medical communications. These abbreviations, symbols and dose designations have been proven to be a barrier to effective communication and have resulted in significant harm to patients. For example, instead of writing “QD” which is often misread as QID, it is acclaimed that health care professionals spell out the word “daily.” The Drugs and Therapeutics Committee at the University Of Cape Coast Hospital mandates all clinicians to prescribe medicines using their generic names devoid of any abbreviations and this is monitored through quarterly prescriber care indicator studies.
The working environment of the health worker, poor lightening at the place of work, poor ventilation, workload, tiredness and frame of mind of the health professional have also been implicated as causes of medication errors.
Ernest Jnr. Ackon Affari
B.sc Physician Assistant studies
University of Cape Coast.
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