This is Section 8, Methods and Tools for Avoiding Medication Errors, thinking about current practices and their place in patient safety. Medications are increasingly complex instruments. We have to think about routes, forms of administration, mechanisms, hazards, the hazards of polypharmacy, and the use of multiple professionals involved in a patient's care. And this is not just for the inpatient setting. It also occurs in the outpatient setting. Medication errors are the most preventable form of patient harm. The Institute of Medicine had reported that one error occurs for every hospitalized patient, and that there may be more than 1.5 million preventable adverse drug events every year, and that around 7,000 deaths per year occur due to medication errors. Well, when thinking about medication errors, it's helpful to think about breaking the process down in terms of prescribing, dispensing, and administration, as well as monitoring, and also monitoring the system that monitors the patient care. There are, as we term latent, there are latent factors that contribute to medication errors, such as when patients are on multiple medications, when there are problems with the medication, when there's poor communication among those who are involved in the patient's care, or from the perspective of the staff, inexperience, or that they're rushing, or that the workplace has no safety culture. Or another latent factor would be the allowance or the way in which drugs may be allowed to be given similar names or abbreviations that are confusing to those who use them. When thinking about preventing medication errors, the clinician needs to understand the process of medications, of giving medications to patients, to think about interventions that may prevent errors, to be able to fill in the gaps when patients have questions, to know the five R's of medication prescribing, and to pay attention to alerts, such as those that come from the Federal Food and Drug Administration. There are also high alert drugs, medications that, when given, have a high risk of harm to patients. While the patient safety culture wouldn't say that one needs to memorize every aspect of every medication, it is important to at least know what are the medications that are high risk and that can create harm. For example, in psychiatry, clozapine. It's important to think about reducing drug name confusion. An FDA alert from June of 2011 spoke to the possibility of confusion between Requip and Risperdal and led to a warning. Similarly, clonazepam, clozapine, clonidine, is another set of medications that are commonly and easily confused. And so it's helpful for practitioners to use generic names, ensure that you're always prescribing for the individual in front of you, have good practice of medication history-taking and medication reconciliation, to be aware, again, of high-risk medications, to know the medications that you prescribe, to not hesitate to use memory aids or other resources, and to consider the use of CPOE when making prescription and when thinking about changing your system. The five R's would be, are you giving the patient the right drug? Is it the right patient? Is it the right amount? Is it rightly written? And do you have or others feel a right to question your order? Those five R's can allow for better patient safety regarding medications. When we think about the patient-centered care model, it's also important to keep patients and their families as a part of the team. They should be encouraged to be involved and to check on medications with regard to educating them about what they're taking, to communicate your plan, to regularly review patient medication lists, and to think that patients, like team members, have a right to question your prescription. From the standpoint of staff, it's important to ensure that all staff taking care of a patient can access information, and electronic medical records are one way to ensure that that can happen. It's also important to make information about medications standardized, to remove problematic abbreviations, and for you to practice medication reconciliation as often as you can, especially when a patient has reported that they've had a change in medications. Also important are practicing legible handwriting, sticking with metric system, using the proper drug name, the exact weight and concentration, and an important point about writing in abbreviations is to never use a trailing zero and to always use a leading zero when using a decimal. To say that again, a leading zero should always precede a decimal expression of less than one. A trailing zero should never be used after a decimal. One should also notate rationale for why you make changes. If needed, include the age and the weight of the patient, do not use vague instructions, and avoid abbreviations, including Latin abbreviations, that are used in outpatient prescriptions. One other set of recommendations for avoiding medication errors comes from the American College of Physicians. Their recommendations include always check your handwriting, avoid the term used as directed, recheck dosage calculations when you make them, use pre-made prescriptions for frequently prescribed medications only, include all pertinent information on prescriptions, do not use abbreviations, and to simply avoid decimals. So again, a leading zero should always precede a decimal expression of less than one. Trailing zeros should be avoided. Some forbidden abbreviations include U for units, IU for international units, Mu G for microgram, and QOD or capital letter QOD for every other day. This slide also includes various other abbreviations that should be avoided, and a full set of abbreviations that should be avoided is available on the website of the Joint Commission. In psychiatry, there are various pairs of names that can easily lead to confusion. Olanzapine, Clozapine, Zyprexa, Zyrtec, Celexa, Celebrex, these are just some, and more will come in the future. So from a patient safety standpoint, it's important to know about these, use generic names as possible, and, as much as we can, to advocate for reduction of confusing names. Here is another slide of more pairs that are confusing. Medication errors can also be addressed through work hours. This is something that certainly has been specifically spoken about in terms of residents and fellows in hospital settings, but practicing physicians also need to pay attention to their own work hours. This is similar to other industries, such as aviation, where crew resource management was applied to make sure that pilots were not working more hours in a row than was safe. Thinking about other ways to reduce errors, pending labs and other studies. When a lab is pending, it may be ignored, but it's best to have a system that prompts you to think about, where is that lab, when am I getting the result? It's been estimated that up to 54% of errors in primary care practices are related to tests. And errors can occur in labs, when the lab personnel misread or don't take in the results, don't tally them correctly. Error-free testing is an ideal. It's something that we all have to watch out for and make sure that our systems try to prevent errors occurring in all aspects of care, including the laboratory and the manners in which the laboratory conveys information to the staff. Diagnostic errors are another source of error. And in fact, when diagnostic errors occur, they are associated with greater morbidity than any other type of error. How do diagnostic errors occur? When shortcuts are taken, when there's premature closure about what is the diagnosis, or in the case of too fast colonoscopies, the procedure is done too quickly and the proper diagnosis is not made. This can happen in just about any field of medicine, but it's important to keep in mind the significance that a diagnostic error can have. Similarly, other errors can occur in surgical site, so choosing the wrong site to do a surgery continues to be a problem in American health care. There are many ways in which methods can be applied to stop this from happening, and various systems have employed timeouts or other preoperative verification to prevent these from happening. These are basic methods. These are not necessarily sophisticated, but these are the things that will prevent errors from occurring due to operating on the wrong side of a patient's body, or the wrong patient, for that matter. Preventing infections is another major component of the patient safety effort. It has been said in some times that the rate of central line-associated bloodstream infections is a tremendous manner of calibrating the safety culture of a hospital, whether it's UTIs, CLABSIs, surgical site infections. Preventing infections is a mark, and the various protocols have been developed to prevent infections from occurring. Hand hygiene may, in fact, help prevent infections. The prevention of infection transmission from patient to patient through hand hygiene is an actual story of good outcomes in the patient safety culture. The efforts that have been put into encouraging clinicians and other members of hospital staff to wash their hands has dramatically reduced infections in hospitals and led to better patient outcomes. The use of a pre-procedure timeout is one basic method that has been used to prevent errors. In this case, a basic method, before any procedure, a team will stop what they're doing, discuss the patient, discuss what is the likelihood of errors within the procedure, what is the eventual outcome, and this is also something that has been associated with reduction in errors. In addition, patient safety culture encourages us to practice and be dedicated to evidence-based medicine. One rationale for the use of evidence-based medicine is that processes and practices are more likely to be recognizable and simplified when EBM is applied.

medication errors

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medication process

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latent factors