Free Continuing Education for Pharmacists Medication Errors

Overview

September 17^th is World Patient Safety day. The World Health Organization (WHO) uses this day each year to increase awareness and recognize patient safety as a global public health concern.¹ Each year in the United States more than 1.5 million medication errors occur, a rate of 171 errors per hour. Annual global costs that are associated with medication errors are estimated at $42 billion, this does not account for lost wages, productivity, or health care costs.² Money is not the only thing being lost to medication errors; the United States is estimated to have 7,000-9,000 deaths each year due to medication errors that could have been prevented. In community pharmacy practice sites, pharmacists and pharmacy technicians play a major role in patient safety and prevention of medication errors as they are the last line of defense before a medication reaches a patient.

What is a medication error?

The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as "any preventable event during the preparation, dispensing, administration, or monitoring of medication use that may cause or lead to inappropriate usage or patient harm."³ Not all errors result in injury or harm; those that do are referred to as preventable adverse effects as the injury is due to a medical intervention and not the underlying condition of the patient. Errors that do result in serious injury or death are referred to as sentinel events. These errors are serious and all factors contributing to them should be thoroughly investigated, analyzed, and reported to appropriate individuals and organizations to guide system-wide improvements.

Why do errors occur?

The Institute for Safe Medication Practices (ISMP) publishes a yearly a top ten list of the most persistent medication errors and hazards. This list focuses on safety problems that were frequently reported, caused serious harm to patients, and could be avoided or minimized with system and practice changes. The 2020 list included errors due to selection of the wrong medication after entering the first few letters of the drug name; this problem has increased greatly with the upswing of technology and may now rival or exceed handwritten order errors.⁴ Another common error that almost always tops ISMP's list is the confusion over drug names that sound or look alike, lookalike product labeling and packaging, or errors involving dosing units or decimal points, misunderstood verbal or telephone orders, and illegible handwriting. An example of lookalike product labeling is shown in Figure 1, with the nearly identical looking bottles of gemfibrozil 600 mg tablets and gabapentin 600 mg tablets, both made by Cipla. Both products have similar looking names and overlapping dosage strengths. The containers also use the exact same colors and font styles.

Figure 1. Look-alike bottles of gemfibrozil 600 mg tablets and gabapentin 600 mg tablets. (Photo: ISMP)

Errors may also occur due to interruptions, fatigue, time pressure, and emotions like anger, fear, or anxiety. It is estimated that pharmacists and technicians that are dispensing medications become distracted or are interrupted as often as once every 2 minutes.⁵ These distractions and interruptions have major consequences as each interruption can increase the possibility of a medication error occurring by 12.7%, this according to a study published in the Archives of Internal Medicine. Medication errors may be due to human errors, but it often results from a flawed system with inadequate backup to detect mistakes such as lack of funding for barcode scanners or updated computer software with safety features built in.

Who to report errors to?

Many health systems have developed their own reporting system for medication errors and near misses. These reports are then reviewed by a safety or med error committee, who make changes to prevent similar errors from reoccurring. Larger corporate community pharmacies may have a similar process to report errors, but there are many other options available for the pharmacies that do not have a reporting system in place. MedWatch is a safety information and adverse event reporting program that was created by the U.S. Food and Drug Administration.³ Another medication error reporting program that is available is through the Institute of Safe Medication Practices. Both reporting programs are free of charge, have a website and a telephone number to call to report errors. It is important to remember that errors or near misses cannot be corrected or reviewed if they are not being reported. Error and near miss reporting are key components in keeping patients safe and preventing the reoccurrence of a medication error.

How to prevent future errors?

Preventing medication errors is not a simple task and this task becomes monumentally harder to accomplish if there are no errors to review, due to fear of retribution for reporting. All healthcare facilities, including all aspects of pharmacy must create a culture of safety. A culture of safety is an atmosphere of mutual trust in which all staff members can talk freely about safety concerns and how to solve them, without fear of blame or punishment.⁶ This type of environment is ideal for staff to report errors, as it allows for errors to be recognized as learning and educational opportunities which will help prevent future errors from occurring. All pharmacy staff including pharmacists, interns, technicians, and clerks are all key players in preventing medication errors from occurring, reaching the patient, and causing harm. It is crucial to remember that most threats to medication safety result from weaknesses or failures within a flawed or faulty system.

Figure 2. An example of a standard written form for recording verbal orders

There are certain strategies that can be easily implemented to help mitigate the medication errors mentioned above. These strategies include typing more than just the first few letters of a drug name, reducing drop-down selection menus, writing verbal or telephone  orders slowly and clearly, create standard written forms to write verbal orders on, reading back the entirety of verbal or telephone orders to review the prescription for accuracy and clarity, incorporate tall-man lettering, avoid abbreviations of drug names, physically separate sound-alike look-alike drugs by placing them at opposite sides of the pharmacy, use bar code technology, incorporate automated dispensing systems where able, and finally, designate certain areas of the pharmacy such as final verification as off-limits to interruptions like phone calls.^2,3,7,8 These are only a few of the many options that can be easily implemented in any pharmacy to help to reduce medication errors and patient harm.

Pharmacists and technicians should be advocates for implementing targeted recommendations to strengthen their practice systems and improve medication safety. Pharmacy staff are the last line of defense in preventing and catching medication errors from reaching the patient. Learning about and increasing awareness to medication error is, why errors occur, who to report errors to, and how to prevent future errors helps to increase patient safety and decrease negative or harmful outcomes.

References

1. World Health Organization. (‎2016)‎. Medication errors. World Health Organization. https://apps.who.int/iris/handle/10665/252274. License: CC BY-NC-SA 3.0 IGO
2. National Priorities Partnership. Preventing Medication Errors: a $21 billion opportunity. National Quality Forum, December 2010. Available at: http://www.nehi.net.
3. Aspden P, Wolcott J, Bootman JL, et al (Eds). Preventing Medication Errors. Institute of Medicine, Committee on Identifying and Preventing Medication Errors. National Academies Press, 2007.
4. "Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards." ISMP, Institute for Safe Medication Practices, 16 Jan. 2020, www.ismp.org/resources/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards.
5. "Side Tracks on the Safety Express. Interruptions Lead to Errors and Unfinished... Wait, What Was I Doing?" ISMP, Institute for Safe Medication Practices, 29 Nov. 2012, www.ismp.org/resources/side-tracks-safety-express-interruptions-lead-errors-and-unfinished-wait-what-was-i-doing.
6. Kohn LT, Corrigan JM, Donaldson MS, Ed. To Err Is Human: Building a Safer Health System. Institute of Medicine: Committee on Quality of Health Care in America. Washington, D.C.: National Academy of Sciences, 2014.
7. Lieder, Tzipora. "10 Strategies to Reduce Medication Errors." Drug Topics Journal, Drug Topics: Voice of the Pharmacist, Apr. 2020, www.drugtopics.com/view/10-strategies-reduce-medication-errors.
8. K.C. Cheung, M.L. Bouvy, P.A. De Smet, Medication errors: the importance of safe dispensing. Br J Clin Pharmacol, 67 (6) (2009 Jun), pp. 676-680

Questions

1. True or False: A medication error is described as any preventable event during the preparation, dispensing, administration, or monitoring of medication that always results in patient harm.

   1. True
   2. False
2. A sentinel event is:
   1. a medication error, but no harm occurs to the patient
   2. a pharmacy event that occurs every 100 years
   3. a medication error that does result in serious injury or death
   4. None of the above
3. Which of these scenarios could result in a medication error?
   1. Confusion in grabbing Novolog or Novolin from the fridge due to similarity in names
   2. Interrupting the final verification pharmacist 15 times due to phone calls
   3. Only typing "met" when searching for metronidazole
   4. All of the above
4. Which pharmacy staff member is responsible for preventing medication errors?
   1. Pharmacists
   2. Interns
   3. Technicians
   4. All of the above are responsible for preventing medication errors
5. What is/are the medication error reporting program(s) available to use free of charge?
   1. MedWatch
   2. CIPLA
   3. ISMP
   4. A & B
   5. A & C
6. True or False: A culture of safety is an atmosphere of mutual trust in which all staff members cannot talk freely about safety concerns or how to solve them, due to fear of blame or punishment.
   1. True
   2. False
7. True to False: Employees should always be blamed, punished, and made an example of when it comes to reporting medication errors, as this is the best way to prevent future medication errors from occurring.
   1. True
   2. False
8. Which of these is NOT a strategy to prevent medication errors?
   1. Using the abbreviation APAP when writing down a verbal order
   2. Utilizing tall man letters to distinguish predniSONE from prednisoLONE on the shelf
   3. Separating sound-alike and look-alike drugs by keeping one in the robot and the other on the pharmacy shelf
   4. Implementing bar-code scanning technology for every drug in the pharmacy

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Source: https://www.sdstate.edu/pharmacy-allied-health-professions/preceptor-training-and-continuing-education/simple-ways-help

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