Medication Safety 3/4/2015. Disclosure. Legal Liabilities. Objectives. SCSHP 2015 Annual Meeting

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1 SCSHP 2015 Annual Meeting Disclosure Karen Snipe, CPhT, MAEd Program Coordinator Trident Technical College Medication Safety I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation Objectives Recognize and appreciate the importance of recognizing and minimizing medication errors. Identify different types of medication errors. Be aware the impact Pharmacy Technicians can have in preventing and / or correcting medication errors. Legal Liabilities Technicians and pharmacists both contribute to the safe use of medications by the public. If their actions result in patient harm, they may both be held legally liable for their actions, along with the institution and others involved. brary/2013/jun;10(2)/publishingimages/fig1_42.jpg 1

2 Contributing Factors to Errors In some studies, an increase in medication errors directly correlated with an increase in the number of patients that the administering staff member was expected to care for. Institutional medication errors are more likely to occur when an administrator of medications has a lack of pharmaceutical knowledge. Overtime and understaffing situations may also contribute to medication errors. Malice or Neglect by Staff In some scenarios, medication errors are not caused by a mistake. Malicious staff members may intentionally administer the wrong medication or a wrong dosage in an attempt to injure the patient or to make the patient easier to care for. Staff may also intentionally skip administering medication to certain patients because of time constraints. Safety Guidelines Several guidelines, institutional safety practices, and technologies are now being put in place in hospitals, clinics, pharmacies, and physician offices to reduce the incidence of medical errors. These include: improved written instructions on all prescriptions, elimination of abbreviations and dosage expressions that can be misinterpreted, use of bar coded wristbands on patients to ensure correct medication administration, and adoption of computerized physician order entry (CPOE) systems similar to those in use at Department of Veterans Affairs (VA) hospitals. Healthcare and shortcuts Throughout healthcare, shortcuts such as abbreviations and symbols are often used to save time when communicating medication orders, especially in handwritten communication. However, some of these shortcuts can be very time consuming for the person on the receiving end and can be dangerous to the patient. Abbreviations and nonstandard dose designations are frequently misinterpreted, and they often lead to errors resulting in patient harm Drug Name Abbreviation A patient dropped off a prescription (Figure) for TAC 0.1% cream to be applied to the affected area twice daily. The doctor was in a rush when writing the prescription, and when he crossed the A and wrote the C it looked like TAZ. The pharmacy technician, seeing TAZ, used the short code TAZ1, which happened to be the short code for the topical acne vulgaris and psoriasis drug Tazorac (tazarotene) 0.1% cream, during order entry. As a result, the pharmacy dispensed Tazorac instead of the prescribed topical corticosteroid triamcinolone. The patient declined patient education as he had previously used triamcinolone. When the patient arrived home, he noticed that the product was different but thought that it was likely the same cream and did not notify his physician or pharmacy. He continued to apply the Tazorac cream to his rash even though it caused burning and did not improve the rash. The patient s physician identified the error during a routine appointment. The patient suffered chemical burns all over his feet and required Silvadene (silver sulfadiazine) cream to treat the burns See more at: Dangerous Abbreviations #sthash.2cuslkjb.dpuf Abbreviation Test AD, AS, AU OS, OS, OU HS, hs QHS, QH, QS SSRI, SSI,SNRI d/c, DC What Drug? AZT MSO4, MgSO4 HCT, HCTZ Nitro drip IV Vanc Norflox, Norflex CPZ PCA 2

3 Don t assume you know the patient A patient requested a refill for zolpidem 10 mg tablets, which she takes at bedtime as needed for sleep. She was unable to pick up the medication herself so asked her father to do so. When he approached the pharmacy counter he told the cashier the patient s last name. The cashier recognized him and asked if he was picking up medications for his daughter. He said, Yes, and the cashier obtained the medication and completed the transaction. Two days later, the patient called the pharmacy to inform them that she had received a medication intended for another patient, one with a similar yet different last name technicianspreventing med errors Wrong Drug Preparation Which of the following would be considered a wrong drug preparation error? a. using the wrong base product to compound a skin ointment b. adding an incorrect volume of water to reconstitute a 80 ml bottle of amoxicillin oral suspension 125 mg / 5 ml c. using the wrong diluent to reconstitute a lyophilized powder for injection d. all of the above In this example, although the order was also communicated verbally, as morphine, the widespread practice of abbreviating drug names (e.g., morph for morphine ) was found to be one of the contributing factors in a fatal event where hydromorphone was given instead of morphine. This example also emphasizes the need for legible handwriting. SALAD = Sound Alike Look Alike Drug Names VinCRIStine VinCRIStine is particularly problematic, and the most frequently reported, because it is often ordered in conjunction with medications that are administered intrathecally (e.g., methotrexate, cytarabine, and/or hydrocortisone). When vinca alkaloids are injected intrathecally, destruction of the central nervous system occurs, radiating out from the injection site. The few survivors of this medication error have experienced devastating neurological damage. 3

4 Intrathecal Drug Administration Vincristine Solution The product labeling also carries a special warning ( For Intravenous Use Only Fatal If Given by Other Routes ). An effective prevention strategy that reduces the risk of inadvertently administering vinca alkaloids via the intrathecal route is to dilute the drug in a minibag that contains a volume that is too large for intrathecal administration (e.g., 25 ml for pediatric patients and 50 ml for adults) Intrathecal drug administration is the introduction of a therapeutic substance into the cerebrospinal fluid by injection into the subarachnoid space of the spinal cord in order to bypass the blood brain barrier. The main indications are for anesthesia and pain management The u, representing the whole word units has often been misinterpreted as a 0 (zero), leading to a 10-fold dose error. Here, the intended 6u was misinterpreted as 60 and the patient received 60 units of regular (short-acting) insulin. Of note, insulin is the most commonly reported medication identified as causing harm in the ISMP Canada database of voluntarily reported medication errors. An example of a hand-written prescription for Metadate ER 10 mg tablets. Metadate is a drug used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Due to the similarity in name, poor penmanship and the omission of the modifier "ER", the pharmacy filling the prescription incorrectly dispensed methadone 10 mg tablets. Methadone is a morphinebased product used as a heroin substitution therapy and analgesic. Methadone is not used for the treatment of ADHD. Measurements The prescription above was written for Femara.Premarin was dispensed and harmed the patient who received it. Measure and express patient weights in metric units only. Ensure that scales used for weighing patients are set and measure only in metric units. Replace current scales that measure in pounds with new scales that only measure weight in grams or kilograms. If scales can measure in pounds and grams/kilograms, modify the scale to lock out the ability to weigh in pounds 4

5 Measurements lb vs kg Ensure that computer information systems and medication device screens (e.g., infusion pumps), printouts, and preprinted order forms list or prompt for weight only in grams (for neonates) or kilograms. Discontinue the documentation of a patient s weight in pounds in all locations, instead document patients weight only using metric designations. Use measured weight rather than a stated, historical, or estimated weight. Rationale Significant medication errors have occurred when the patients weight is documented in non metric units of measure (e.g., pounds) and it has been confused with kilograms (or grams). Numerous mistakes have been reported when practitioners convert weights from one measurement system to another, or weigh a patient in pounds but accidentally document the value as kilograms in the medical record, resulting in more than a two fold dosing error Oral Syringes Goal of Best Practice Ensure that all oral liquids that are not commercially available as unit dose product are dispensed by the pharmacy in an oral syringe. Use only oral syringes marked Oral Use Only. Ensure that oral syringes used do not connect to any type of parenteral tubing used in the hospital. Use of an auxiliary label For oral use only is also preferred, since the print on the oral syringe is small, if it does not obstruct critical information. The goal of this best practice is to prevent the unintended administration of oral medications via the intravenous route. ISMP continues to receive reports in which patients were inadvertently given an oral liquid medication intravenously. This happens most often when an oral liquid is prepared extemporaneously or dispensed in a parenteral syringe that connects to vascular access lines IV Syringe Tip Leur Lock Oral Syringe Slip tip Glacial Acetic Acid vs Acetic Acid (vinegar) Goal of Best practice Accidental topical application of glacial (greater than or equal to 99.5%) acetic acid has repeatedly resulted in serious patient harm, including severe pain and serious tissue damage, third degree burns, and in one case, bilateral leg amputation. Often in these cases, this item was either accidentally purchased or used in place of a much more diluted form of acetic acid, such as vinegar or a commercially available 0.25% acetic acid solution. The goal of this best practice is to prevent harm from the use of glacial acetic acid applied directly to patients. The use of hazardous chemicals in pharmacy compounding or for special therapeutic procedures and diagnostics is common in many hospitals. Patient harm has occurred when toxic chemicals have been misidentified as oral products, or when a very concentrated form of a chemical has been erroneously used in treating patients 5

6 Risks of Taking Meds during Pregnancy & Lactation In this example, an octreotide infusion was administered at 25 ml/h instead of 5 ml/h as intended. Whether handwritten or computer-generated, symbol can be misread as the number 2 or 5, leading to substantial overdoses of medication The FDA issued a new rule that changed how drug companies are required to present the risks of taking medicine during pregnancy and while breast feeding. The current system, described as confusing and outdated by physicians, used letters of the alphabet to denote risk, with X being the most dangerous. The new system, which will be implemented in June, breaks the risk into three parts pregnancy, lactation and fertility and requires companies to give a summary of the risk, including information on existing human studies and on adverse reactions caused when the drug was taken during pregnancy or lactation. FDA New Rule It requires that more information about drugs will be provided than ever before, and in a manner that speaks directly to the concerns that doctors and their patients are likely to have. The rule will apply to all new prescription drugs and biologics, but not to over the counter medications. Additionally, it also will apply to drugs approved since 2001 that have been marketed for years without including updated information related to pregnancy and lactation New Information The pregnancy subsection will include information on dosing and potential risks to a developing fetus and carry information on any registries that collect data on how the drug affects expectant mothers. The lactation subsection will provide information on how much of the drug will transfer to breast milk and the potential effects it could have on a breastfeeding child. The subsection on reproductive potential will include information on a drug s influence on pregnancy testing, contraception and infertility. Rx vs OTC Be vigilant about safety issues with any prescription or over-the-counter medications you have at home, and be aware of what to do in an emergency situation if you suspect that a child has ingested something poisonous Checking Correct Information When the patient first drops off the prescription taking 10 seconds to make sure all the correct information is there can prevent so many errors. Is the patient s name spelled out completely (first and last name)? I don t know how many times I have seen a prescription with just the first letter of the patient s first name on a prescription; then it was filled for a sibling of the patient. Is the date of birth written large and clear? Can you read what the medication is, directions, quantity, and the doctor s name? If you answer no to any of these questions, now is the time it can be addressed. Does the patient know what medication is prescribed for them? Does the patient know how they are taking the medication? If there is any question whatsoever, call the doctor and get clarification. 6

7 Checking Correct Information The last opportunity to catch any possible mistakes is when the patient comes back to pick up their prescription. Verifying the name of the patient on the prescription bottle along with the medication name will ensure they are picking up the correct prescription. When the technician has a lot of experience they will also be able to estimate the correct quantity in the bottle and recognize the tablets are in fact the medication listed on the bottle. Having a second set of eyes look at the prescription can help reduce up to 90% of errors Patient Medication Error Causes Many medication errors are caused by patient mistakes. Elderly patients may have a multitude of different medications prescribed, and may become confused about when to take which medications. Confusion can result in missed medication, medications being taken twice, or errors in dosage and timing. In some cases, pill distribution machines may also malfunction. Contributing Factors to Patient Errors Patients may begin to lose cognitive function, contributing to medication errors. Patients may also begin to lose eyesight, which can cause prescription labels to be misread or misunderstood. Patients may attempt to crush, split, or mix the medication in order to make taking the medications easier, and may inadvertently contradict instructions. All of these medication errors can result in injury to the patient. Family Medication Error Causes Family members may be responsible for medication errors, if a family member is administering medication for an elderly patient. Family members may inadvertently misread directions, medication names, or dosages. Family members may also intentionally administer the wrong dosage or miss medications in order to steal the medications or for other malicious reasons Med Error News Vaccine Errors look alike/sound/alike names DTaP for Tdap ; Pediatrix for Boostrix; Hib for HepB ; Flumist (Live vaccine) for Fluzone similar packaging don t rely on coloring of vial caps, labeling or packaging Adacel (Pertussis) and Engerix B (Hep. B) both have orange caps Preparation missing requirements Not mixing Menveo powder (meningitis) with its liquid component Vaccine Preparation Ensure vaccines are prepared lose stability cause bacterial growth in the syringe 7

8 Vaccine Storage Keep most vaccines and their intended diluent together but beware of exemptions Zostavax diluent must be stored in the refrigerator Unreconstituted Zostavax must be stored in the freezer Letting certain vaccines come to room temperature or removing a lightsensitive vaccine (ProQuad, etc) from its original packaging.can lead to loss of vaccine potency and loss of $$$ to your pharmacy Credits for Hospitals.pdf ges/19.aspx canada.org/dangerousabbreviations.htm family/articles/971239/watch out thesedrugs look like candy errors/causes/ technician news/medicationerrors pharmacy technicians are on the front line of this escala PREVENTING MEDICATION ERRORS ASHP Daily Briefing ashp_daily_briefing@ashp.custombriefings.com Pharmacy Technician s Letter Vol 9, No.1 QUESTIONS?? 8