Medication Safety And The Role Of The Pharmacy Technician

10/4/2014Objectives Presented by Leslie Sanchez, Pharm.D.New Mexico Society of Health System Pharmacists2014 Balloon Fiesta Symposium Define medication error and explain the reasons for reportingmedication errors.Identify the incidence of medication errors and the impact onthe patient and healthcare system associated with them.Describe the critical components in the medication use processand identify common types of medication errors that may occurin the medication use process.Discuss specific techniques used to evaluate and reducemedication errors.Describe the role a pharmacy technician has in preventingmedication errors and promoting patient safety.Patient SafetyWHO defines patient safety as the prevention of errorsand adverse effects to patients associated with healthcare. In developed countries as many as one in 10 patientsis harmed while receiving hospital care. Hospital infections affect 14 out of every 100 patientsadmitted. 20-40% of all health spending is wasted due to poorquality of care1. Medication ErrorA medication error is “any error occurring in themedication use process”. 2 The National Coordinating Council for Medication ErrorReporting and Prevention (NCC MERP) defines amedication error as: “ .any preventable event that may cause or lead to inappropriatemedication use or patient harm while the medication is in the control ofthe health care professional, patient, or consumer. Such events maybe related to professional practice, health care products, procedures,and systems, including prescribing; order communication; productlabeling, packaging, and nomenclature; compounding; dispensing;distribution; administration; education; monitoring; and use.”21World Health Organization: 10 Facts on Patient Safety; http://www.who.int/features/factfiles/patient safety/en/Medication Error (Y/N)Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. 1995. Relationship between medication errors and adverse drug events. Journal of General Internal Medicine 10(4):100–205.Incidence and Impact of Medication Errors A patient is seen in clinic and prescribed Bactrim DS. After a couple of doses thepatient returns to the clinic due to hives and itching. The pharmacy dispensed cefazolin 2 grams instead of cefepime 2 grams. Theincorrect medication was not given to the patient because the nurse noticed the wrongmedication was dispensed. The provider wrote a prescription for the patient to receive 150 mg enoxaparinsubcutaneous twice a day. The pharmacy filled the prescription as ordered. Thepatient should have received this dose once a day. No harm to the patient wasevident. The patient was instructed to take Augmentin twice daily for a sinus infection. After acouple of days the patient experienced GI side effects and quit taking the medication.They went to urgent care and received a different antibiotic to treat the sinus infection. Serious medication errors occur in 5-10% of patientsadmitted to hospitals.The FDA estimates that 1.3 million people are injuredannually in the US following medication errors.Adverse drug events cause more than 770,000 injuries anddeaths each year and cost up to 5.6 million per hospital.Medication errors cost the U.S. 4 billion a yearThere are 7,000 deaths per year (19 deaths per day) dueto medication errors33National Patient Safety Foundation; esource-center/definitions-and-hot-topics/#MedErr1

10/4/2014Self-AssessmentWhich of the following is a medication error?A.B.C.D.Patient LR received a medication labeled for Patient BS.Luckily, the medication, dose, and route were the same so no patientharm resulted.The Automated Dispensing Cabinet (ADC) on the nursing unit was outof docusate sodium. The medication was charted as not given and thenext dose was given on time.When the patient was admitted to the hospital he stated an allergy tocodeine. This was not recorded in the patient’s chart. The patientreceived multiple doses of acetaminophen with codeine and neverexperienced signs of an allergic reaction.All of the aboveThe Medication Use Process Prescribing Order Processing Preparation and Dispensing Administration Effects MonitoringTen Key Elements of theMedication Use Process Patient information Drug information Communication of drug information Age, height, weight, allergies, labs Among health care teamDrug labeling, packaging andnomenclature Sound-Alike Look-Alike Drugs (SALAD),product labeling Safety assessment before and afteracquisition References, protocols, formulary Drug device acquisition, use andmonitoringDrug storage, stock, standardization,and distribution Standardize administration times, drugconcentrations, limit availability Environmental factors Staff competency and education Poor lighting, noise, interruptions,workload New medications, processes, errors,PrescribingCorrect medication for the patient based on current illnessand patient medical history It is estimated that up to 39% of medication errors occurduring prescribing Common errors: high-alert medications Dosing errorsPatient Education Drug names, indication, doses Incorrect medicationQuality Processes and RiskManagement Drug/drug interactions Redesign systems and processes to Drug/allergy interactionsprevent errorsSafety Measures Utilized DuringPrescribing and Order ProcessingOrder Processing Approximately 12% of medication errors occur during orderprocessingCommon errors Factors influencing prescribing and order processing errors Wrong drug, dose, dosage form, frequency Errors of Omission Environmental factorsConformational biasUse of error prone abbreviationsSound-Alike Look-Alike DrugsLack of patient information Verify patient information Clarify illegible handwritingUtilize technology Height/weight, allergies, lab values Computerized Provider Order Entry (CPOE) Dose Range Checking (DRC) Allergy and drug interaction checking Be aware of and avoid known error prone abbreviationsCaution with Sound-Alike Look-Alike DrugsHigh-alert drugsUtilize tall-man lettering2

10/4/2014Error Prone AbbreviationsSound-Alike Look-Alike Drugs (SALAD) Tall -man lettering Utilize brand and generic drug name Configure computer selection screensto prevent the drug names appearingconsecutively Change the appearance of theproduct Special auxiliary labelingISMP's List of Confused Drug NamesSafety Measures Utilized forHigh-Alert MedicationsHigh-Alert MedicationsThe Institute for Healthcare Improvement (IHI) defineshigh-alert medications as:“ .medications that are most likely to cause significant harm to thepatient, even when used as intended. Although any medication usedimproperly can cause harm, high-alert medications cause harm morecommonly and the harm they produce is likely to be more serious andleads to patient suffering and additional costs associated with care ofthese patients.” Packaged differently Implement doublechecks Auxiliary labeling Automated alerts Patient education ighalertmedicationsafety/pages/default.aspxSelf AssessmentWhich of the following is least likely to result in a wrongdose error?A. 0.1 UB. 10.0 unitsC. .1 mgD. 10 mgSelf AssessmentYou are working at a retail pharmacy and the parents ofAiden, a 4 year-old, are dropping off a prescription.What information should you request from the parents?A. WeightB. Allergy informationC. Date of birth and insurance informationD. All of the above3

10/4/2014Safety Measures Utilized in thePreparation and Dispensing ProcessPreparation and Dispensing The correct medication and dose are prepared anddispensed appropriately for the patient.Approximately 11% of medication errors originate duringthe preparation and dispensing processCommon errors Wrong medication, dose, or dosage formWrong concentration or diluentWrong technique – possible contaminationImmediate vs extended release productsErrors of omission/wrong timeWrong or missing auxiliary labeling Technology Automated Dispensing Cabinets (ADCs)Utilize barcode technologyRobotic IV preparation devicesPumps and software to manage total parenteral nutrition (TPN)preparations Sterile preparation workflow technology (ex. Chemocato and DoseEdge) Pneumatic tube medication delivery Develop processes which focus on inventory management Sufficient supply Expiration date monitoring Appropriate storage conditions based on manufacturer package insertSafety Measures Utilized in thePreparation and Dispensing ProcessAppropriate staff training and certification for sterileproduct preparation Special precautions for SALAD and high-alertmedications Separate dosage forms (oral vs topical) Standardize concentrations and product inventory Purchase ready-to-use (RTU) products when available Minimize environmental influences Standardize medication administration times AdministrationThe medication is administered to the patient asprescribed It is estimated that up to 38% of medication errors arerelated to administration Common errors Safety Measures Utilized During theAdministration Process10 Rights of Drug Administration Right DrugRight PatientRight DoseRight RouteRight Time and FrequencyRight DocumentationRight History and AssessmentDrug Approach and Right to RefuseRight Drug-Drug Interaction and EvaluationRight Education and InformationWrong patientWrong medicationWrong doseWrong time or omissionWrong route Technology Bar Code Medication Administration (BCMA)Automated Dispensing Cabinets (ADCs)Electronic medication administration recordsInfusion pumps with drug librariesIndependent double-checksQuiet-zones during medication administration Standard medication administration times Patient education and involvement 4

10/4/2014Effects Monitoring Side-effects and adverse drug reactions (ADR) Duration of therapy Effectiveness of therapy Drug levels for medications requiring monitoringSelf AssessmentWhat is an environmental factor that may contribute toa medication error during any step of the medicationuse process?A. It is raining outsideB. Multiple interruptions or distractionsC. The paint in the medication room is fluorescent pinkD. There is a full moon Aminoglycosides, antiepileptics, vanocmycin, anticoagulants,immunosuppressive agentsError Detection MethodsImportance of Reporting Medication Errors Identify educational gapsIdentify the root cause of errors with the goal ofimproving the medication use systemData gathered may assist in identifying priority areasfor improvementReporting Errors Institute of Safe Medication Practices (ISMP) National Medication Errors Reporting Program (ISMP MERP) National Vaccine Errors Reporting Program (ISMP VERP) Food and Drug Administration (FDA) MedWatch Program Vaccine adverse drug reaction (VAERS) Medical Device Reporting (FDA MDR) New Mexico Board of PharmacyThe manufacturer of the medication, vaccine, or deviceInternal reporting programs Voluntary Reporting Trigger Tools Observation Chart Review Patient ComplaintSelf AssessmentWhile working in the IV room you notice that a few vials ofvancomycin have a particulate in the solution. Afterconsulting with the pharmacist in the inpatient area it isdecided that all vials from that lot are to be sequesteredfrom working stock. If it is determined that the particulatewas not introduced during reconstitution in the IV room,where should this be reported?A. FDA MedWatchB. ISMP MERPC. The manufacturerD. Any of the above5