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Medication Safety. A medication error is a drug error that may or may not reach the patient It is usually preventable It is usually unintentional May or May not cause harm A medication error that causes death is called a sentinel event by the Joint Commission

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medication safety
Medication Safety
  • A medication error is a drug error that may or may not reach the patient
    • It is usually preventable
    • It is usually unintentional
    • May or May not cause harm
  • A medication error that causes death is called a sentinel event by the Joint Commission
  • When a sentinel event occurs the institution is required to perform a root cause analysis
type of medication errors
Type of Medication Errors
  • Prescribing Errors
    • Involves wrong dose, illegible sigs, wrong frequencies
    • Incorrectly transcribing verbal orders from MD
  • Dispensing Errors
    • Results from mistakes made during dispensing
    • Physically preparing medications incorrectly (i.e. using 23.4% saline instead 0.9% saline for an IV admixture)
    • Transcribing sig instructions incorrectly
      • i.e. Methothexate 12.5 mg tablet TIW as 12.5 mg TID
    • Error is dosing calculations
  • Administration Errors
    • Involves nursing
    • Incorrect route of administration
      • Giving KCL 40 meq IVP instead of KCL 40 meq IVPB over 60 minutes (FATAL)
      • Giving Vincristineintrathecally instead of intravenously (Fatal)
      • Giving Penicillin G Benzathine IV instead of IM (can be fatal)

Causes of Medication Errors

    • Performance problems
    • Procedure(s) not followed
    • Knowledge deficits
    • Pharmacists/Pharmacy Technicians that may be intoxicated by alcohol or drugs
    • Social or Family problems
    • Noise level at work
    • Distractions
medication error reduction strategies
Medication Error Reduction Strategies
  • Joint Commission “Do not use” list
  • ISMP (Institute for Safe Medication Practices) error prone do not use list
    • See Lesson 3 “Medical and Pharmacy Terminology”
    • Also see
    • ISMP also publishes a list of confused drug names
      • Example concludes Celebrex-Celexa
      • List can be found at

Tall Man Lettering

    • Tall Man lettering is a strategy implemented by healthcare institutions in the US under the advise of the Joint Commission , FDA and ISMP
    • Involves drug names that can be confused with one and other, see ISMP confused name’s list
    • Drugs with similar sounding names or spelling are called LASA drugs-Look Alike Sound Alike drugs
    • Tall man lettering involves the use of mixed case lettering to distinguish between these drugs
    • Examples:
      • buPROPion VS busPIRone
      • glyBURide VS glipiZIDE
      • hydrALAZINE VS hydrOXYzine
    • Tall man strategies involves: labeling of these medications, ADC cabinet display, separating these drugs on pharmacy shelves

High Alert Medications

    • Medications that when used in error can result in serious patient harm including death
    • ISMP has collected a list of such drugs

High Alert Medication Strategies

    • US hospitals and healthcare institutions have published their own lists that mirrors the ISMP list with some additions.
    • Strategies include:
      • Specialized color code labeling for these medications
      • Segregating the medications in the pharmacy inventory
      • Restricting access to these drugs in the ADC (non overrideable)
      • Specialized alerts in the CPOE and the pharmacy systems
      • Use of standardized preparations of these drugs
        • i.e. Heparin USP 25,000 units/250 ml D5W

Do Not Crush List

    • ISMP publishes a do not crush list
    • These drugs should never be crushed
    • Typically patients that can’t swallow or have feeding tubes, NG tubes and PEG tubes have their oral dose forms crushed and administer in about 30 ml of liquid
    • Crushing some drugs alters their time course of activity, stability, or exposure potential to pharmacy personnel
      • Drugs that are long acting
        • Effexor XR, Cardizem CD, Detrol LA, KDUR, Paxil CR, Seroquel XR
      • Drugs that are enteric coated
        • Ecotrin
        • Depakote
        • Nexium
      • Powerful GI irritant
        • Actonel®
      • Teratogenic (exposure to female pharmacy personnel)
        • Isotretinoin
      • Sublingual Dose Forms
        • Nitroglycerin
how to report med errors and adverse drug events
How to report med errors and adverse drug events
  • FDA Medwatch
  • ISMP MERP database
  • Institute of Medicine (IOM)
  • TJC (Joint commission)
  • USP Medmarx
  • FDA and CDC VAERS system for vaccines