SCRIPT: medication errors

Question 1

Types of error.

a) Give the main types
b) How are they prevented?

Answer 1

• Lack of knowledge (mistakes)
• Forgetfulness (lapses) - one or more step omitted
• Fumbles (slips) - one or more step executed incorrectly
• Violation - deliberate deviation from usual protocol

b) - Mistakes prevented via education and training
- Lapses and slips prevented via systems improvement (eg. better staffing, prompts)

Question 2

Seven deadly sins of prescribing

Answer 2

• Not knowing your patient
• Not knowing your drug
• Failing to take adequate DHx
• Writing an illegible prescription
• Using inappropriate abbreviations, decimals and leading zeroes
• Failing to calculate and check drug doses correctly
• Giving unclear instructions

Question 3

Medication errors.

a) Define
b) What % medical errors are related to medication?
c) How much can this be reduced by e-prescribing?
d) Who should be notified of any errors?
e) In a 5-step process, if the error rate is 10% at each step, what is the overall likelihood of success?

Answer 3

a) A failure in the treatment process whether through omission or commission that leads to, or has the potential to lead to, harm to the patient
b) 10 - 20 %
c) ~ 50%

d) - The patient (duty of candour)
- Senior in charge of patient
- The hospital trust (?Datix)
- National Reporting and Learning System (NRLS)

e) 0.9 x 0.9 x 0.9 x 0.9 x 0.9 = 0.59 (59% success rate)

Question 4

Medication error: classification

failure to do X…. at the right dose… for the right patient

Answer 4

• Prescribing errors - failure to order the right drug* at the right dose at the right frequency for the right patient.
• Most commonly this is the OMISSION of a drug on admission to hospital that should have been prescribed (particularly analgesia)
• Dispensing errors - failure to supply the right drug at the right dose at the right frequency for the right patient.
• Preparation errors - failure to prepare the right drug at the right dose for the right patient.
• Administration errors - failure to administer the right drug at the right dose by the appropriate route and method for the right patient.
• Monitoring errors - failure to check the administration and effect of a medicine.

Question 5

Systems error: Swiss Cheese Model

a) Latent conditions
b) Active failures

Answer 5

a) - Workload
- Staffing levels
- Lack of training or supervision
- Communication problems between healthcare staff (eg. hierarchical disparity, poor handovers)
- Deficiencies in the design of technology (can be manipulated - eg. mechanical blocks)

b) Errors and violations

Question 6

Acting on medication errors.

a) Immediate action
b) Next steps

Answer 6

a) Prompt and appropriate clinical treatment to prevent any further harm to the patient

b) - Multidisciplinary consultation on plan of action
- Apologise to patient/ family and discuss the mistake and the plan of action
- Local reporting - trust, ?Datix
- National reporting - NRLS - trends related to patient safety risk will be translated into patient safety alerts and fed back to organisations

Question 7

Never events.

a) Define
b) Administration errors
c) Specific at-risk medicines

Answer 7

a) A patient safety incident that:
- is entirely preventable
- has the potential to result in serious harm or death

b) - IV chemotherapy given via the intrathecal route
- Oral/enteral medication or feed/flush administered by any parenteral route
- IV administration of a medicine intended to be administered via the epidural route

c) - Antimicrobials
- Anticoagulants
- Insulin
- Anti-parkinson medicines
- Resuscitation medicines - eg. adrenaline, amiodarone
- Chemotherapy/ cytotoxic (eg. methotrexate)
- Potassium

Question 8

Medication error: not knowing the drug

Answer 8

• Wrong drug
• Wrong dose
• Wrong formulation
• Wrong frequency
• Wrong duration
• Wrong route
• Wrong rate of administration (if IV - eg. vancomycin, slow infusion over 60 mins)
• Failure to consider contraindications, interactions, etc.
• Failure to monitor appropriately