S M Leung

Clinical Pharmacist
Queen Mary Hospital
What is Medication Incident (MI) ?
Errors in medication management process:
Prescribing
Dispensing
Administration
Compliance
What is Medication Incident ?
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.
Such events may be related to professional
practice, health care products, procedures, and
systems
The National Coordinating Council for Medication Error Reporting and Prevention
Medication Incidents
Incidents that reached patient
Involves the actual erroneous administration
or omission of a drug to a specific patient
Near miss
Does not involve the actual administration of
the drug
The error is detected and corrected before
the drug reaches the patient
Severity Index
SI =0 SI = 1 SI = 2 SI = 3 S1 = 4 SI = 5 SI = 6
Incident
occurred but
stopped
before
reaching
patient.
No
consequence
Incident
occurred
(reached
patient) but
no injury
sustained
Minor injury
Temporary
morbidity
Significant
morbidity
Major
permanent
loss of
function/
disability
Death
May have
required
monitoring.
No
investigatio
n is
required
Required
monitoring
&/or
investigatio
n
Required
monitoring
&/or
investigation
Required
transfer to a
higher care
level
No change
in vital
signs
Some
changes in
vital signs
Significant
changes in
vital signs
No
treatment
required
Required
minor
treatment
(e.g. simple
wound care,
analgesic)
Required
simple
treatment
(e.g
suturing)
Required
emergency
treatment /
surgical
intervention
Number of MI Involving Medical Staff (HKWC)
107
2 1
253
262
224
313
383
5 5
7 6
9
4
1
3 2 1 1 1 1
0
100
200
300
400
2008 2009 2010 2011 2012
S0
S1
S2
S3
S4
No. of MI
Year
Types of MI Committed by Medical Staff
(in HKWC, year 2012)
183
45
28 28
26
24
22
11
4
1
1
22
0
50
100
150
200
Wrong
Strength/Dosage
Wrong
Frequency
Wrong Drug Wrong Dosage
Form
Wrong Route Know Drug
Allergy
Wrong Patient Wrong
Abbreviation
Wrong Duration Double Entry Drug Omission Others
395 MI reported
No. of MI
Transamin 1 cap TDS PO PRN x 4/7
(Tranexamic acid)
Illegible Handwriting
Prednisolone
Non-approved Abbreviation
daily
instead of QD
Wrong Drug Name
Boehringer Ingelheim
is the name of a drug company !
Wrong Drug
Specialty: Endocrine
Prescription
1.
CARBIMAZOLE tablet
oral: 15mg daily for 12 weeks
2.
PROPANTHELINE tablet
oral: 10 mg tds for 12 weeks
Should be Propranolol
For relieve of thyrotoxic symptoms
Wrong Dose
Wrong Frequency
Drug Allergy: No Known drug allergy
Prescription
1.
ASPIRIN ENTERIC COATED (CARTIA) tablet
oral: 100mg daily for 11 weeks
2.
FAMOTIDINE (PEPCIDINE) tablet
oral: 20mg qid for 11 weeks
3.
ATORVASTATIN (LIPITOR) tablet
oral: 10mg daily for 11 weeks
Usual frequency: daily or BD
Wrong Duration
For 1 week
Known Drug Allergy
Drug Allergy: (1) Ampicillin
Prescription
1.
AMMONIA AND IPECACUANHA (MES) mixture
oral: 2 x 5ml spoonful(s) tid for 3 days
2.
AQUEOUS (30g) cream
topical : tid for 2 weeks, dispense 1 tube
3.
CEFUROXIME AXETIL (ZINNAT) tablet
oral: 500 mg bd for 1 week ** fix period **
Prescription
1.
PARACETAMOL tablet
oral: 1 tablet(s) qid for 5 days
2.
ALUMINIUM / MAGNESIUM HYDROXIDE AND SIMETHICONE (TRIACT) tablet
oral: 1 tablet(s) tds prn (100%) for 5 days
3.
NAPROXEN (NAPROSYN) tablet
oral: 250mg tds prn (100%) for 5 days
4.
METHYL SALICYLATE COMPOUND (ANALGESIC BALM) ointment 20g
topical: tds for 5 days
5.
PARACETAMOL tablet
oral: 1 tablet(s) qid for 5 days
6.
COLCHICINE tablet
oral: 0.5mg tds for 5 days
Double Entry
Incorrect Computer Entry
Prescription
1.
DILTIAZEM HCL tablet
oral: 30 mg tds for 1 weeks
2.
WARFARIN SODIUM tablet
oral: 3 mg once per day (on even days) for 1 weeks, then
3.5 mg once per day (on odd days) for 1 weeks
3.
AMIODARONE HCL tablet
oral: 200 mg daily for 1 weeks
4.
MODURETIC tablet
oral: 0.5 tablet(s) daily for 1 weeks
3 mg once per day (on even days) and
3.5 mg once per day (on odd days)
for 1 weeks
Medication Administration Record (MAR)
For In-patient
Medication Order Entry (MOE) Prescription
For Out-patient
Manual
Prescription
Total Parenteral Nutrition (TPN)
Order Form
Chemotherapy
Protocol
MAR forms in QMH
The MAR form is a triplicate copy,
including a top working sheet for use on
wards, and two duplicates underneath
for obtaining drug supply from pharmacy
5 different MAR forms for use on all
wards
Oral &
Non-Injection
Regular
Prescription
For all regularly
scheduled items
given by routes
other than injection
e.g. oral /
sublingual / topical
Injection
Regular
Prescription
For all regularly
scheduled items
given by injectable
routes
e.g. IV / IM / SC
As Required /
Emergency
Medicine Ward
Prescription
For all items given
on an as required
basis regardless of
route
For Emergency
Medicine Ward, this
is the only MAR
used
Once Only
Prescription
For all items to be
given on a single
occasion without
immediate intention
of repeating
Continuous
Infusion
Prescription
For all items to be
given by infusion
Provide patient particulars
affixing the correct patients bar-coded gum
label in the gum label box under the serial
number
Fill in Diagnosis, Drug Allergies & History
Must check either of the drug allergy boxes. If Yes,
provide details of drug and reactions
Provide Body weight and / or Body height
Doctor to sign & provide staff number
Enter only one preparation in each MAR box
Complete the On / Off date
the On date should be the date when the
medicine was FIRST prescribed, not when the
MAR is rewritten
Off date may be left blank if medication is
continuing
Ensure Drs signature & staff number is on each
line of prescription
Provide Overriding Reason
when intentionally prescribing a drug that a patient
is known / possibly allergic to
may use alphabetical codes provided under
Patient Gum Label box
Pharmacists Remarks
Clinical pharmacists may provide advice,
precautions or instructions on the use of
medications
Special Notes for As Required /
Emergency Medicine Ward (EMW) MAR
Route of administration must be specified
especially for EMW MAR, since all drugs
regardless of routes are on the same form
Special Notes for Once Only MAR
one line for each item, with no Off Date
Must specify the route as all dosage forms
may be prescribed on this form
Special Precautions
Not to use any abbreviations on
HAs Do Not Use list
UseDaily
insteadofQD
Special Precautions
Do not use any Non-HA Approved /
Non-HA Standard
F/E??
FleetEnema
intended!
Special Precautions
Specify correct dosage form for the right
dose, e.g. Gliclazide MR for modified-
release tab
Gliclazide MR30mgtab
x2,or
Gliclazide 80mgtab
x3/4?
Special Precautions
Do not use Q8H for over 8 hours could be
mistaken for one dose every eight hours
Write
Over8hours
Before Initiating any Drug Orders
Check patient name & ID
gum label
computer record
Lab. result
Before Initiating any Drug Orders
Check the drug allergy history
Document known drug allergies
On every page of MAR / drug chart
No known drug allergy
Yes, please specify ________
Ensure patient has no allergy to proposed
medication
Checking for Drug Allergy
Ensure any allergy alerts in CMS are
relevant at the time of prescribing
Re-check, verify & amend drug allergy
record
Update newly identified drug allergy into
CMS as soon as possible
Avoid free-text computer entry
Drug Allergy
Most common drug groups:
Beta-lactam antibiotics
penicillins
cephalosporins
Carbapenems
NSAIDs & aspirin
Cross-sensitivity
Drug Allergy
Compound preparation
Augmentin, Unasyn, Tazocin, Timentin, Sulperazon
Neozep (Paracetamol + Chlorpheniramine, etc)
DrugOffice,DepartmentofHealth
Before Initiating Drug Orders
Verify total drug profile
current drug profile in all specialties
complete medication history
Rx, OTC, alternative medicine
Ensure the medication order is
clear and unambiguous
Write legibly
Write firmly using indelible black/blue ink
Prescribe in full text
use approved abbreviations only
Do not prescribe with ambiguous dosing
instructions
Do not use abbreviations as listed in the HA Do
Not Use List
Record in the patients note the medicine
prescribed & justify the reasons for the choice
HA Do Not Use List in Prescribing
frequently misinterpreted and involved in harmful
medication errors or near misses
HA Do Not Use List in Prescribing
Do Not Use Use Instead Potential Problem
Trailing zero after
decimal point
(e.g. 5.0 mg)
5mg
(no zero after decimal)
10-fold overdose if
decimal point is not
seen
Omission of zero
before decimal point
(e.g. .5mg)
0.5mg
(use zero before decimal)
10-fold overdose if
decimal point is not
seen
HA Do Not Use List in Prescribing
Do Not Use Use Instead Potential Problem
u or U units Misinterpreted for 0 or 4
iu or IU units Misinterpreted for IV or 10
q.d., qd, Q.D., QD
o.d., od, O.D., OD
daily Misinterpreted as qid
q.o.d, qod, Q.O.D., QOD on alternate days Misinterpreted as qd
or qid
mcg, g microgram Misinterpreted as mg
List of HA-wide Approved Abbreviations
Either prescribe in full
text or adhere to the
list of approved
abbreviations
List of HA-wide Approved Abbreviations
Drug Name
Use generic name as far as possible
Unless
combination product e.g. Augmentin
bioavailability issues e.g. Nuelin, Theodur
Take particular care when prescribing drugs
with look-alike or sound-alike names
Look-Alike Sound-Alike (LASA) Drug Names
Different Dosage Forms of the Same Drug
Prescribing Errors associated with LASA
Incorrect selection of a similar drug name
on the selection screen during computer
MOE
Drug name is not written clearly on the
MAR and is misinterpreted by pharmacy
or nursing staff
To prevent medication incidents
associated with LASA
Write legibly
Specify the dose &
dosage form
Do not use
abbreviations
Specify indication
when appropriate
Dosage
Specify dosage form and strength if multiple
preparations exist
Use metric system
e.g. 5ml instead of 5cc or 1 spoonful
Expressed in terms of active ingredients
except in the case of compound preparations
e.g. Amlodipine 5mg instead of 1 tablet
Checking the Dosage
For patients under 12 years old
age, height and weight should be available
For adults
weight is desirable for drugs which require
precise dosage e.g. chemotherapy
Double check calculations by another qualified
colleague for high alert medications
Frequency & Times of Administration
For medications given once or twice a week
state the actual days to be given
e.g. Methotrexate on Friday only
Checking for Contraindications &
Drug Interactions
Relevant lab. results
Concomitant disease
Concurrent or recent medicines
Any previous adverse reaction to medicine
Discontinuing Prescription
Rewrite the order for any amendment
to the prescription
Draw a single line diagonally across
the MAR order box
Specify the off date and sign
MOE Prescribing
Choose Right patient
Choose Right drug, dosage form
Enter Right dose, frequency & duration
Review the whole MOE prescription before
and after printing it out
Discharge Medications
Prescribe ALL the medications the patients
are currently taking
When the supplies of certain medications
are not required, indicate as keep record
only
Ensure patients are aware of any changes
to the medication upon discharge
compared with their previous medications
Tips for Prescribing
Familiarize with the medication ordering
system
Evaluate the patients total status and review
all existing drug therapy before prescribing
new or additional medications
Stay abreast of the current state of knowledge
Seek information when prescribing for
inexperienced conditions
Always double check prescriptions
Medications Incident Reporting
Both incidents that reached patient &
near miss should be reported
Reported by frontline
Entirely voluntary & strictly confidential
Emphasizes on learning rather than
blaming
Advanced Incidents Reporting System (AIRS)
Mandatory reporting events
Sentinel Events (SE)
Medication error resulting in major
permanent loss of function or
death
Serious Untoward Events (SUE)
Medication error which could have
led to death or permanent harm
report through AIRS within 24 hours
Atropine 10mg given instead of
Adenosine Triphosphate (ATP) 10mg
A patient was admitted because of hyperkalaemia
Patient complained of chest pain, SVT was shown on
ECG
Junior Dr consulted on-call Dr who gave a verbal order
of ATP 10mg IV
Junior Dr gave verbal order of ATP 10mg to a new
nurse. The nurse received the verbal order as
Atropine 10mg and handed 10 ampoules of Atropine
to Dr
Junior Dr withdrawn 8.3 ampoules and administered
the medication to patient
Atropine 10mg given instead of
Adenosine Triphosphate (ATP) 10mg
Patients heart rate was ~220bpm, BP
107/70mmHg. Junior Dr discovered that the
drug given was Atropine (1.2mg/ml 1ml)
instead of ATP (10mg/ml 2ml)
Patient lost consciousness with unrecordable
blood pressure. CPR was initiated
Atropine 10mg given instead of
Adenosine Triphosphate (ATP) 10mg
Key contributing factors:
Communication of verbal order among staff
Failure to counter-check the identity of medication
Incompetence
the nurse had insufficient knowledge of the drugs
lack of awareness of risk when 9 amp. of the drug was
withdrawn
Voltaren SR given to a patient with
known allergy to Mefenamic Acid
A patient with known drug allergy to Ponstan
(Mefenamic Acid) and Flu Medicine was admitted for
elective Caesarean section
Allergy column on MAR: only Flu medicine was
recorded
Known Drug Allergy label was not stuck on MAR
Patients identity bracelet: Red clip was not used
Patients bed: Known allergy signage was not posted
up
Voltaren SR given to a patient with
known allergy to Mefenamic Acid
Voltaren SR 100 mg daily PRN PO was prescribed
A nurse sent off duplicate copy of MAR to Pharmacy
for dispensing
Patient complained of pain
A nurse obtained Voltaren SR from a pack of
discharged patients medication, checked with another
nurse and administered to patient
Drug allergy alert was returned from pharmacy
Voltaren SR was stopped. Patient did not show
allergic reaction
Voltaren SR given to a patient with
known allergy to Mefenamic Acid
Key contributing factors:
Not verified allergy status according to system
information during prescribing
Verified allergy status according to MAR only
during administration
Bypassed pharmacy vetting system and used
discharged patients medication
Monthly Medication Incident Report
HA Guidelines on Medication Management
Prescribing, Dispensing and Administration
Prescribing Guidelines
Dispensing Guidelines
Administration Guidelines
High Risk Medications in HA
Categories
1 concentrated electrolytes
2 cytotoxic chemotherapy
3 drugs commonly associated with drug allergies
e.g. penicillin, aspirin, NSAIDs
4 vasopressors and inotropes
5 anticoagulants including heparin
6 neuromuscular blocking agents
e.g. atracurium, pancuronium
7 oral hypoglycaemics
8 insulins
9 Narcotics / opioids
e.g. fentanyl
have the highest risk of causing injury when misused
Medication Safety Committee Guidelines
Guidelines on safe management of:
KCl IV solutions
Concentrated electrolytes
Intrathecal chemotherapy
Continuous epidural analgesia
Medication Safety Committee Guidelines
Safety Solutions on:
Look-alike & Sound-alike medications (LASA)
High risk medications
Medication Safety Bulletin,
MIRP Bulletin,
Risk Alert