Medication Safety

1. Medication Safety Dr. KanarHidayat 2016-2017

2. Medication Safety Programme • This programme aims to improve medication safety in the health and disability sector by focusing on reducing harm from medication errors and addressing unwarranted variation and inequities to improve consumer outcomes.  

3. Errors • Adverse Drug Event: an injury resulting from a medication or lack of intended medication • Improper Dose Error: administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient • Medication Error: 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.

4. Patient Groups At Risk • Patients on multiple medications • Patients with another condition, e.g. renal impairment, pregnancy • Patients who cannot communicate well • Patients who have more than one doctor • Patients who do not take an active role in their own medication use • Children and babies (dose calculations required)

5. Medication Reconciliation • The process of identifying the most accurate list of all medications used by a patient • The list contains also: name, dosage, frequency and route • To provide correct medications for patients anywhere within the health care system • Reconciliation: comparing patient’s current list against admission, transfer and/or discharge

6. Example

7. Prescribing Error • Incorrect drug selection based on: • Indications • Contraindications • Known allergies • Existing drug therapy • Dose and Dosage form • Quantity • Route • Concentration • Instructions for use

8. Key Positions • Responsible persons who: • Prescribe • Prepare • Dispense • Administer • Monitor drug therapy

9. How can prescribing go wrong? • Lacking of knowledge about drug indications and contraindications • Not considering individual patient factors such as allergies, pregnancy, co-morbidities, other medications • Wrong patient, wrong dose, wrong time, wrong drug, wrong route • Inadequate communication (written, verbal) • Documentation - incomplete, ambiguous • Mathematical error when calculating dosage • Incorrect data entry when using computerized prescribing e.g. duplication, omission, wrong number

10. Look-a-like and sound-a-like medications

11. Medication history taking • Include name, dose, route, frequency, duration of every drug • Enquire about recently ceased medications • Ask about over-the-counter medications, dietary supplements and alternative medicines • Make sure what patient actually takes matches your list: • be particularly careful across transitions of care • practice medication reconciliation at admission to and discharge from hospital • Look up any medications you are unfamiliar with • Consider drug interactions, medications that can be ceased and medications that may be causing side-effects • Always include allergy history

12. Staff Errors • Inexperience • Rushing • Doing two things at once • Interruptions • Lack of checking and double checking habits • Poor teamwork and/or communication between colleagues • Reluctance to use memory aids

13. Monitoring errors • Lack of monitoring for side-effects • Drug not ceased if not working or course complete • Drug ceased before course completed • Drug levels not measured, or not followed up on • Communication failures

14. Role of Electronic Medical Record (EMR)

15. Summary • Medications can greatly improve health when used wisely and correctly • Medication error is common and is causing preventable human suffering and financial cost • Remember that using to help patients is not a risk-free activity • Know your responsibilities and work hard to make medication use safe for your patients • Read chapter 10 Medication Safety, The Pharmacy Informatics Primer, DoinaDumitru

16. Questions?