Medication Safety

Question 1

Define Adverse Drug Event (ADE)

Answer 1

Injury due to medication. May be preventable or non-preventable, and are costly and result in significant additional healthcare resource consumption

Question 2

Define Medication error

Answer 2

Any preventable event that may lead to inappropraite medication use or patient harm while medication is in control of HCP/patient/consumer

Question 3

Consequences of medication error

Answer 3

1. AE, causing harm to patient
2. Near miss, where patient is nearly harmed
3. Neither harm nor potential for harm

Question 4

List the type of medication errors that may occur

Slide 10-12

Answer 4

1. Dose: Omission (excl. non-adherence), improper, wrong rate/ duration/ time/ route
2. Drug: Wrong drug/ dosage form/ strength, monitoring error (e.g. DDI, CI), expired
3. Personnel: Wrong technique/ patient
4. Others that are not under the above categories

Question 5

The nine categories of patient outcomes resulting from medication errors

Answer 5

Categories A - I
A: Can potentially cause error
B: Error caught before reaching patient
C: Error occurred, no harm to patient
D: Error occurred, rq monitoring, no harm
E: Error cause temporary harm rq intervention
F: Error cause temporary harm rq hospitalisation
G: Error cause permanent harm
H: Error cause near death (e.g. coma)
I: Error caused death

Question 6

Define “Near Miss”

Answer 6

• Event/situation that could have resulted in medication error, but did not.
• If ignored, may lead to medication errors

Question 7

Compare the incidence of Near misses VS minor injuries VS Major injuries

Answer 7

Near misses are 10 to 100x more frequent than adverse events

Question 8

According to WHO, describe the data/trend of medical errors worldwide

Answer 8

• 1 in 10 patients harmed while receiving healthcare
• 43 mil safety incidence annually
• US$42b cost due to medication error

Question 9

Where do medication errors occur?

Answer 9

At any point in the medication use process

Question 10

Which step in the medication use process has its errors least intercepted hence most likely to cause harm?

Answer 10

Administration step

Question 11

Outline the procedure of prescribing

Answer 11

1. Choose individualised med appropriate for clinical situation
2. Select Administration route, dose, time, regimen
3. Communicate plan with whoever administering medication and patient
4. Document Rx

Question 12

How can prescribing go wrong and lead to medication errors?

Answer 12

1. Inadequate knowledge about drug indications and C/I
2. Failure to consider individual factors (e.g. allergy)
3. Wrong patient/ dose/ time/ drug/ route
4. Inadequate verbal and written communication
5. Poor documentation quality (e.g. illegible)
6. Mathematical errors in calculating dose
7. Incorrect data entry when using computerised prescribing (e.g. omission, duplication)

Question 13

Outline the procedure of Dispensing

Answer 13

1. Transcribe of Rx
2. Review and confirm Rx
3. Prep/pack meds
4. Distribute to patient location
5. Document
6. Dispense + counselling

Question 14

How can dispensing go wrong and lead to medication errors?

Answer 14

1. Poor inventory organisation
2. Transcription error (e,g, order 10 items, miss one)
3. Failure to check for individual factors
4. Documentation problem
5. Math error when calculating dosage/ qnty
6. Miscommunication

Question 15

Outline the procedure of medication administration

Answer 15

1. Obtain ready-to-use meds
2. Check for allergy
3. Give right med to right patient, with right dose, route and time
4. Document

Question 16

How can administration go wrong and lead to medication errors?

Answer 16

Wrong:

1. Drug
2. Route
3. Time
4. Dose
5. Patient

and

6. Omission
7. Inadequate documentation and communication

Question 17

Outline the procedure of monitoring medication use

Answer 17

1. Observe patient to ensure proper use and effect of medication, and not harming patient
2. Monitor for therapeutic response and ADR
3. Document

Question 18

How can monitoring go wrong and lead to medication errors?

Answer 18

1. Lack monitoring for ADR
2. Drug not stopped if not working
3. Drug stopped before course completion
4. Drug levels not measured nor followed-up
5. Communication failure

Question 19

The broad factors that can cause medication errors

Answer 19

1. Patient factors
2. Medication/Tech design factors (poor manufacturing, distribution practices and complex/poorly designed tech)
3. Staff/Human factors and communication errors
4. System and workplace factors

Question 20

Name some examples of patient factors that pose high risk of medication error

Answer 20

1. Multiple meds or health condition
2. Polypharmacy (more than one doctor)
3. Specific conditions (e.g. preg)
4. Unable to communicate well
5. Not playing active role in own med use
6. Children and Babies (where dose calculations required)

Question 21

Name some examples of poor drug manufacturing/ distribution practices that can lead to medication errors

Answer 21

1. Packaging:
   - Inappropriate, lead to dosage form confusion
   - Inaccurate/incomplete labels
   - Misleading/confusing info
   - Distracting symbols/logo
   - Product of same strength too similar
   - Different products too similar
   - Too similar to another manufacturer
   - Too similar within same company’s product line
2. Drug: Look-alike, sound-alike (LASA)

Question 22

Name some examples of poorly designed technology that can lead to medication errors

Answer 22

1. Malfunction
2. Usage of wrong devices
3. Adapters for different tubings too compatible
4. Automated machines
5. Difficult to distinguish PO measuring devices with parenteral devices
6. Infusion

Question 23

Name some situations that can contribute staff/human factor and lead to medication error

Answer 23

1. Knowledge deficit
2. INexperience
3. Rushing
4. Multi-tasking (distracted)
5. Interruptions
6. Fatigue/ bored/ on “auto-pilot”
7. Lack checking habits
8. Violate SOP
9. Reluctance to use memory aids
10. Poor teamwork/communication

Question 24

Name some communication failures between staff that can lead to medication errors

Answer 24

1. Unclear handwriten and oral communication
2. Missing/misplaced zeros/ decimal points
3. Using non-standard abbreviations
4. Ambiguous/incomplete orders
5. Confusion:
   - LASA drugs
   - Drug with different formulation/conc.
   - unit of measurements

Question 25

Name some examples of system/workplace factors that can lead to medication errors

Answer 25

1. Workplace:
   - Bad lighting and noise
   - Frequent interruptions and distractions
   - No safety culture
   - Inappropriate storage of medications
2. System
   - Inadequate training/supervision
   - Patient and medication info not readily available
   - Inadequate manpower (e.g. lack available HCP)
   - Breakdown of computerised systems

Question 26

The Swiss cheese model of harm illustrates the concepts in patient safety, that:

Answer 26

• Both latent unsafe conditions and active failures contribute to harm
• Harm results when layers of defence in system fail to prevent hazard from reaching patient (holes of cheese aligned)

Question 27

What is “Latent Errors”?

Answer 27

Errors in system that are not obvious, and people try to overcome it with or without noticing it

E.g. Bad lighting

Question 28

Why are latent errors the greatest threat to safety in a complex system?

Answer 28

• They lead to operator errors as they are failures in-built to the system and present long before the active error
• They are not obvious, and staff are accustomed to working around them

Question 29

The error that is the greatest contributors to any accidents in industries, including healthcare

Answer 29

Human error

Question 30

Define Root Cause Analysis (RCA). When an error has occured, what does RCA focus on such that it is called “systems approach to error”

Answer 30

• Definition: Systematic approach to understanding causes of AE and identify system flaws (i.e. latent errors) that can be corrected to prevent error recurrence
• Focus: system causes and vulnerabilities, not just the error and persons involved

Question 31

RCA is usually conducted by a team of 4 to 6 people. Who should be inside the RCA team?

Answer 31

Team should be interprofessional
- Include individuals at all levels of organisation who have fundamental knowledge of issues and processes involved in incident

Question 32

What is the 3 questions in a simplified RCA?

Answer 32

1. What happened? Describe the key processes the led to the failure
2. What went wrong and why? Identify the failed processes
3. Suggest risk reduction strategies and implementations that can prevent recurrences

Question 33

Recall the hierarchy of effectiveness of risk-mitigation strategy.

If a risk-mitigation strategy is classified as “least effective”, can we omit that strategy?

Answer 33

Not all the time, as those strategies may be appropriate and important

E.g. team needs more training and education to ensure error does not occur again

Question 34

List some ways to reduce the risk of medication error

Answer 34

1. Reduce reliance on human memory (e.g. bar-coding)
2. Simplify
3. Standardise (especially abbreviations)
4. Use forcing and constraints functions
5. Use protocols and checklists wisely
6. Improve access and ease of access to information
7. Decreased reliance on vigilance
8. Reduce Handsoff
9. Differentiate, else eliminate LASA
10. Automate carefully

Question 35

What are high-alert medications?

Answer 35

Drugs with high risk of causing significant patient harm when used incorrectly, with devastating consequences

Question 36

What are the error-preventing strategies for high-alert medications?

Answer 36

1. Improve access to info about drugs
2. Limit access
3. Use aux labels and automated alerts
4. Standardise ordering, storage, preparation and administration
5. Employ automated/independent double-checks

Question 37

The standardised high-alert medications reference list

Answer 37

1. Meds administered via intrathecal and epidural routes
2. Anaesthetics
3. Anticoagulants and Thrombolytics
4. Chemo
5. Concentrated electrolytes
6. Hypoglycaemic agents (and insulin)
7. Inotropes (e.g. digoxin)
8. Neuromuscular agents
9. Opiates
10. Radio-contrast agents
11. Sedatives (both parenteral and PO)
12. Vasopressors (e.g. adrenaline)

Question 38

Describe the receommended guideilnes for High-alert medications management

Answer 38

1. Eliminate/reduce possibility of error:
   - Remove from clinical areas,
   - Reduce amount stocked
   - Limit available concentrations
2. Make errors visible: have independent double-checking for infusion pump before administration
3. Minimise consequence of errors:
   - Change practices to reduce AE of errors if it occurs
   - Close monitoring to improve early detection of erros and prompt remedial action by institute

Question 39

What are some ways to manage LASA drugs to reduce medication errors?

Answer 39

1. Store similar looking meds separately
2. Repackage/ re-label
3. Alert staff on meds with LASAs
4. Avoid stocking look-alike packages
5. Use striking caution stickers on stock containers
6. Tall man lettering

Question 40

Describe “Standardise”, a strategy used to reduce medication error

Answer 40

1. Standardise prescribing conventions E.g. generic names, abbreviations
2. Protocols for complex med administration
3. Standardise times of drug administration
4. Store meds in same place in every medication room
5. Use standard equipment (e.g. one kind of pump)

Question 41

Hospital X has this practice where patients with certain conditions have colour-coded wristbands (E.g. allergies, MRSA). Which step to reduce errors does this fall under?

Answer 41

Improve access to information

Question 42

Safe electronic communication of medication orders:

Answer 42

1. Use generic name
2. avoid including salt of chemicals
3. differentiate generic name from brand names
4. standardise inclusion of suffixes
5. standardise use of mnemonics or short names
6. standardise fonts and colours