MEDICATION SAFETY

Medications are the most common treatment intervention used in healthcare around the
world. When used safely and appropriately, they contribute to significant improvements
in the health and well-being of patients. Medicines are generally safe when used as
prescribed or as directed on the label, but there are risks in taking any medicine.

Medication safety issues can impact health outcomes, length of stay in a healthcare
facility, readmission rates, and overall costs to healthcare system

The 5 Rs of Medication Safety:

 Right Drug

 Right Route

 Right Time

 Right Dose

 Right Patient

The 5 Moments for Medication Safety tool can be applied at different levels of care
and in different settings and contexts. It can be used when patients:

 visit a primary health care facility

  Admission/discharge/Transfer

ERRORS WHICH CAN LEAD TO MEDICATION ERROR

1. Prescription error

 Not considering individual patient factors, such as allergies, pregnancy, co-

morbidities, polypharmacy

 Inadequate knowledge about drug indications and contraindications

 Wrong patient, wrong dose, wrong time, wrong drug, wrong route

 Inadequate communication (written, verbal)

 Documentation - illegible, incomplete, ambiguous

 Mathematical error when calculating dosage

 Incorrect data entry when using computerized prescribing e.g. duplication,

omission, wrong number
2. Administration error

 Wrong patient

 Wrong route
  Wrong time

 Wrong dose

 Wrong drug

 Omission, failure to administer

 Inadequate documentation
3. Dosage calculation errors (especially in child & aged patient)
4. Monitoring Failure: How can monitoring go wrong?

 Lack of monitoring for side-effects

 Drug not ceased if not working, or course completed

 Drug ceased before course completed

 Drug levels not measured, or not followed up

 Communication failures

SITUATIONS LEADING TO MEDICATION ERROR:

 Inexperience

 Rushing

 Doing two things at once

 Interruptions

 Fatigue, boredom, being on “automatic pilot” leading to failure to check and

double-check

 Lack of checking and double checking habits

 Poor teamwork and/or communication between colleagues

 Reluctance to use memory aids

LASA Drugs:

Look Alike Sound Alike (LASA) medications involve medications that are visually similar
in physical appearance or packaging and names of medications that have spelling
similarities and/or similar phonetics. As more medicines and new brands are being
marketed in addition to the thousands already available, many of these medication
names may look or sound alike. Confusing medication names and similar product
packaging may lead to potentially harmful medication errors.

Common Risk Factors Common risk factors associated with LASA medications
includes:

 Illegible handwriting

 Incomplete knowledge of drug names

 Newly available products

 Similar packaging or labeling

 Similar strengths, dosage forms, frequency of administration

 Similar clinical use

Strategies to avoid errors with Look Alike Sound Alike Medications

1. Procurement
2. Storage
3. Prescribing
4. Dispensing/ Supply
5. Administration
6. Monitoring
7. Information
8. Patient Education
9. Evaluation
1. Procurement:
(a) Minimise the availability of multiple medicines strengths.
(b) Whenever possible, avoid purchase of medicines with similar packaging
and appearance.
2. Storage:
a. Use Tall Man lettering to emphasise differences in medications with
sound-alike names. Tall Man lettering (or Tallman lettering) is the practice of
writing part of a medicines name in upper case letters to help distinguish
soundalike, look-alike medications from one another to avoid medication errors
 Examples of Tall Man lettering are metFORMIN and metoPROLOL.
b. Use additional warning labels for look-alike medicines.
c. Separate storage
3. Prescribing:
(a) Write legibly.
(b) Prescription should clearly specify name of medication, dosage form,
dose and complete direction for use.
(c) Include the diagnosis or medication’s indication for use. This
information helps to differentiate possible choices in illegible orders.
(d) Whenever possible, drug names in computerised prescriber order entry
(CPOE) should Tall Man lettering.
(e) Communicate clearly. Take your time in pronouncing the drug name
correctly
4. Dispensing/Supply:
(a) Identify medicines based on its name and strength and not by its
appearance or location.
(b) Check the appropriateness of dose for the medicines dispensed.
(c) READ medication labels carefully at all dispensing stages and
perform triangle check.
(d) Double checking should be conducted during the dispensing and supply
process.
(e) Highlight changes in medication appearances to patients upon dispensing.
5. Administration:
a. Read the medication labels carefully
b. Apply triangle check: It is to check actual medicines against prescription
and medication labels
6. Monitoring:
a. The LASA list of the hospital needs to be updated regularly
b. Implement feedback mechanism to inform on LASA drugs
7. Information:
a. All relevant persons should have an access to LASA list
 b. Staff should be informed on the new updates in the LASA list
8. Patient Education:
(a) Inform patients on changes in medication appearances.
(b) Educate patients and their caregivers to alert healthcare providers
whenever a medication appears to vary from what is usually taken or
administered.
(c) Encourage patients and their caregivers to learn the names of their
medications.
9. Evaluation:
Evaluate medication errors related to LASA medications.