STRATEGY OF THE PHARMACIST IN REDUCING

MEDICATION ERRORS IN HOSPITAL

ASSOCIATE PROFESSOR LITA CHEW

PHARMACY DEPARTMENT, NATIONAL UNIVERSITY OF SINGAPORE
HEAD, DEPARTMENT OF PHARMACY, NATIONAL CANCER CENTRE SINGAPORE
CHIEF PHARMACIST, MINISTRY OF HEALTH SINGAPORE
LEARNING OBJECTIVES

 Defining and Classify

medication errors
 List the causes of medication
errors
 Describe strategies to
prevent/reduce medication
errors
 ERROR / MISADVENTURE
 Definition:

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 provider, patient, or consumer
 Such events may be related to professional practice, health care products, procedures, and systems,
including prescribing, order communication, product labelling, packaging, and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring, and use

 Adverse event: any undesirable experience associated with the use of a

medical product in a patient
 Near miss: an unplanned event that did not result in injury, illness, or damage –
but had potential to do so
3

The National Coordinating Council for Medication Error Reporting and Prevention. https://www.nccmerp.org/about-medication-errors
 THE SCALE OF THE PROBLEM
 Estimating the prevalence of medication errors is difficult due to the
varying definitions and classification systems employed. Rates can vary
depending on the denominator used (patient, prescription or a specific
medication). The challenge is compounded by variations in health care
system organization and the availability and use of incident reporting
systems
 1–2% of patients in UK and US hospitals are thought to be harmed by
medication errors1
 Worldwide, medication errors cost an estimated US$42 billion annually. This is
0·7% of the total global health expenditure2
4

1. Br J Clin Pharmacol. 2009 Jun; 67(6): 621–623.

2. http://www.who.int/patientsafety/medication-safety/en/
 1. NCC MERP Taxonomy of Medication Errors
2. NCC MERP Index for Categorizing Medication Errors

The National Coordinating Council for Medication Error Reporting and

Prevention. https://www.nccmerp.org/about-medication-errors
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team Factors associated with health care professionals

- Lack of therapeutic training
 Patient
- Inadequate drug knowledge and experience
 Medicine - Inadequate knowledge of the patient
 Work environment - Inadequate perception of risk
- Overworked or fatigued
 Task
- Physical and emotional health issues
 Computer system - Poor communication
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team Factors associated with patients

- Patient characteristics (e.g., personality,
 Patient literacy and language barriers)
 Medicine - Complexity of clinical case, including multiple
 Work environment health conditions, polypharmacy and high-
risk medications
 Task
 Computer system
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team Factors associated with medicine

 Patient - Naming of medicines
- Labelling and packaging
 Medicine
 Work environment
 Task
 Computer system
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team Factors associated with the work environment

- Workload and time pressures
 Patient
- Distractions and interruptions (by both primary care
 Medicine staff and patients)
- Lack of standardized protocols and procedures
 Work environment
- Insufficient resources
 Task - Issues with the physical work environment (e.g.,
lighting, temperature and ventilation)
 Computer system
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team Factors associated with the task

- Repetitive systems for ordering, processing and
 Patient authorization
 Medicine - Patient monitoring (dependent on practice, patient,
other health care settings, prescriber)
 Work environment

 Task
 Computer system
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team Factors associated with the task

- Repetitive systems for ordering, processing and
 Patient authorization
 Medicine - Patient monitoring (dependent on practice, patient,
other health care settings, prescriber)
 Work environment

 Task
 Computer system
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS
Factors associated with computerized information systems
 Provider/Care team
- Difficult processes for generating first prescriptions (e.g.
 Patient drug pick lists, default dose regimens and missed alerts)
 Medicine - Difficult processes for generating correct repeat
prescriptions
 Work environment - Lack of accuracy of patient records
 Task - Inadequate design that allows for human error

 Computer system
 Primary-secondary care interface
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 FACTORS THAT MAY INFLUENCE MEDICATION ERRORS

 Provider/Care team
 Patient
 Medicine
 Work environment Primary-secondary care interface
 Task - Limited quality of communication with secondary care
- Little justification of secondary care recommendations
 Computer system

 Primary-secondary care interface

Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
 MEDICATION-USE SYSTEM IN HOSPITAL
The pathway connecting a clinician's decision to prescribe a medication and the patient
actually receiving the medication consists of several steps:

Transcribing Dispensing Administration

Prescribing - reading and interpreting - pharmacist checking for - Nurse giving correct
- clinician selecting the the prescription correctly drug–drug interactions and medication to the correct
appropriate medication and allergies, then release the patient at the correct time
the dose, frequency, and appropriate quantity of the
duration medication in the correct
form
Fallibility is part of the STRATEGIES TO PREVENT MEDICATION
human condition. ERROR IN HOSPITAL
We cannot change the
human condition.
But we can change the  Physician /Nursing/ Pharmacy Champions
conditions under which
- Decreased perception that any dept is a barrier to
people work.
patient care
- Build cooperation among practitioners

 Safety is a system property

- Build transparency in system
- Information flow established within system
- Build independent checks within the system
 IS THERE A SAFER SYSTEM FOR PRESCRIBING?
 Study of inpatient medication errors found that
approximately 90% occurred at either the ordering or
transcribing stage.
- These errors had a variety of causes, including poor handwriting,
ambiguous abbreviations, or simple lack of knowledge on the
part of the ordering clinician

 A CPOE system can prevent errors at the ordering

and transcribing stages by (at a minimum) ensuring
standardized, legible, and complete orders.
 CPOE systems are generally paired with some form of
clinical decision support system
Design work so that it is easy to do it right
and hard to do it wrong
 IS THERE A SAFER SYSTEM FOR PROCESSING
AND PREPARATION AND DISPENSING?

 Clinical pharmacists to oversee medication dispensing

process
Arch Intern Med. 2006;166(9):955-964.
doi:10.1001/archinte.166.9.955 - Institute of Medicine reports recognized that pharmacists are
an essential resource in safe medication use, that participation of
pharmacists on rounds improves medication safety, and that
pharmacist-physician-patient collaboration is important
 Use of "tall man" lettering and other strategies to
minimize confusion between look-alike, sound-alike
medications
 Automated dispensing cabinets for high-risk
medications
IS THERE A SAFER SYSTEM FOR
ADMINISTRATION?
 Minimize interruptions to allow nurses to
administer medications safely
 Barcode medication administration to ensure
medications are given to the correct patient
 Smart infusion pumps for intravenous
infusions
 Patient education and medication labels
to improve patient comprehension of
administration instructions
DEVELOPING A SAFETY CULTURE…

Leaders
 Create open learning environment
 Learn to measure risk; Learn when to
console & when to coach staff
 Strive to understand why human errors
& why at-risk behaviors occur
 Learn to see common threads – to
prioritize risk & interventions
 Work with staff to design systems that
reduce the rate of human error and at-
risk behavior, or mitigate their effects 21
https://www.ismp.org/guidelines/best-practices-hospitals
 MEDICATION
WITHOUT HARM:
WHO'S THIRD
GLOBAL PATIENT
SAFETY
CHALLENGE

https://www.youtube.com/watch?v=MWUM7LIXDeA

Medication Without Harm aims to reduce severe avoidable medication-related harm by

50%, globally in the next 5 years. It was formally launched at the Second Global Ministerial
Patient Safety Summit in Bonn, Germany on 29 March 2017.

http://www.who.int/patientsafety/medication-safety/en/
 DEFINITION
SUGGESTED READINGS

CAUSE
 Books

PREVENTION
 1.Cohen, Michael R., Ed. Medication Errors. Washington, D.C. American
Pharmaceutical Association. 1999. (Contains a special chapter on high-
alert medications and dangerous abbreviations; rich with insight and

MANAGEMENT
practical advice on reducing the risk of error.)
 2.Corrigan, Janet, et al. To Err is Human: Building a Safer Health System.

REFERENCES
Washington, D.C. National Academies Press. 1999. (Comprehensive
overview of medical error, containing many practical suggestions and
recommendations from several trusted sources.)
 3.Leape, Lucian, et al. Reducing Adverse Drug Events. Boston, MA:
Institute for Healthcare Improvement. 1998. (Concepts to reduce
adverse events and a model for improvement.)

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 DEFINITION
SUGGESTED WEBSITES

CAUSE
• Institute for Safe Medication Practices (ISMP) www.ismp.org

• Joint Commission on Accreditation of Healthcare Organizations

PREVENTION
(JCAHO) www.jcaho.org
• California Institute for Health Systems Performance (CIHSP)

MANAGEMENT
www.cihsp.org
• National Coordinating Council for Medication Error Reporting and

REFERENCES
Prevention (NCCMERP) www.nccmerp.org
• VA National Center for Patient Safety www.patientsafety.gov
• American Hospital Association www.aha.org

• US Pharmacopeia (USP) www.usp.org

• Med-E.R.R.S. www.med-errs.com

• American Society of Health-system Pharmacists (ASHP) www.ashp.org

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THANK YOU