|
| A) | For the purpose of meeting ISMP requirements for pharmacies | ||
| B) | To help take disciplinary action against employees | ||
| C) | To report errors to The Joint Commission | ||
| D) | For error tracking and prevention |
It's important to define exactly what a medication error is and what a medication error isn't. This allows medication errors to be identified by healthcare providers, patients, administrators, and national organizations that track errors, such as ISMP. Once a medication error is identified, strategies can be developed to prevent it from happening again.
| A) | It eliminates errors in the prescribing step. | ||
| B) | It reduces the risk of missing information. | ||
| C) | Dose defaults ensure the right dose is always prescribed. | ||
| D) | Quantity defaults ensure the patient always gets the right quantity. |
E-prescribing helps to reduce some types of prescribing errors. Prior to electronic prescribing, one pediatric ambulatory clinic found 77.4% of prescriptions contained at least one error compared with 4.8% after the institution of electronic prescribing. Before electronic prescribing, the most common errors were attributed to missing essential information (73.3%) or illegibility (12.3%). After the start of electronic prescribing, the rate of missing information declined to 1.4% and illegibility was eliminated [22].
| A) | .0075 g | ||
| B) | .00750 g | ||
| C) | 7.5 mg | ||
| D) | 7.50 mg |
DANGEROUS ABBREVIATIONS
| Abbreviation | Intended Meaning | Potential Error | Recommendation | |||||
|---|---|---|---|---|---|---|---|---|
| The Joint Commission's "Do Not Use" List | ||||||||
| U, u | Unit | Mistaken for "0" (zero), the number "4" four, or "cc" | Write "unit" | |||||
| IU | International unit | Mistaken for IV (intravenous) or the number "10" (ten) | Write "international unit" | |||||
| qd, QD, q.d., Q.D. | Daily | Mistaken as every other day (qod) or four times daily (qid) | Write "daily" | |||||
| qod, QOD, q.o.d., Q.O.D. | Every other day | Mistaken as daily (qd) or four times daily (qid) | Write "every other day" | |||||
| Trailing zero (X.0 mg) | X mg | Decimal point is missed | Write X mg | |||||
| Lack of leading zero (.X mg) | 0.X mg | Decimal point is missed | Write 0.X mg | |||||
| MS | Morphine sulfate or magnesium sulfate | Confused for the opposite intended | Write "morphine sulfate" | |||||
| MSO4 | Morphine sulfate | Confused for magnesium sulfate | Write "morphine sulfate" | |||||
| MgSO4 | Magnesium sulfate | Confused for morphine sulfate | Write "magnesium sulfate" | |||||
| Examples of Other Abbreviations to Avoid | ||||||||
| µg | Microgram | Mistaken as milligram (mg) | Use mcg | |||||
| > and < | More than and less than |
| Use "more than" or "less than" | |||||
| @ | At | Mistaken as the number "2" | Use "at" | |||||
| cc | Cubic centimeters | Misread as "u" (units) | Use "mL" | |||||
| Apothecary units (e.g., minims, grains) | Varies | Confused with metric units; unfamiliar to some healthcare professionals | Use metric system | |||||
| APAP | Acetaminophen | Not recognized as acetaminophen | Use complete drug name | |||||
| CPZ | Compazine (prochlorperazine) | Mistaken as chlorpromazine | Use complete drug name | |||||
| HCT | Hydrocortisone | Mistaken as hydroCHLOROthiazide | Use complete drug name | |||||
| HCTZ | HydroCHLOROthiazide | Mistaken as hydrocortisone | Use complete drug name | |||||
| MTX | Methotrexate | Mistaken as mitoXANTRONE | Use complete drug name | |||||
| PTU | Propylthiouracil | Mistaken as Purinethol (mercaptopurine) | Use complete drug name | |||||
| SSI | Sliding scale insulin | Mistaken as Strong Solution of Iodine (Lugol's) | Use "sliding scale (insulin)" | |||||
| SSRI | Sliding scale regular insulin | Mistaken as selective serotonin reuptake inhibitor | Spell out "sliding scale (insulin)" | |||||
| TAC | Triamcinolone, tacrolimus |
|
| |||||
| / (slash mark) | Separates two doses | Mistaken as the number 1 (e.g., 25 units/10 units misread as 25 units and 110 units) | Use "and" rather than a slash mark to separate doses | |||||
| Qhs | Nightly at bedtime | Mistaken as qhr (every hour) | Use QHS or qhs for bedtime | |||||
| TIW or tiw | Three times a week | Mistaken as 3 times a day or twice in a week | Use 3 times weekly | |||||
| BIW or biw | Two times a week | Mistaken as 2 times a day | Use 2 times weekly | |||||
| SC, SQ, sq, or sub q | Subcutaneous(ly) |
| Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly) | |||||
| D/C | Discharge or discontinue | Premature discontinuation of medications if D/C (intended to mean discharge) on a medication list has been misinterpreted as discontinued | Use discharge and discontinue or stop | |||||
| AD, AS, AU | Right ear, left ear, each ear | Mistaken as OD, OS, OU (right eye, left eye, each eye) | Use right ear, left ear, each ear | |||||
| OD, OS, OU | Right eye, left eye, each eye | Mistaken as AD, AS, AU (right ear, left ear, each ear) | Use right eye, left eye, each eye | |||||
| UD | As directed (ut dictum) | Mistaken as unit dose (e.g., an order for "dilTIAZem infusion UD" mistakenly administered as a unit [bolus] dose) | Use as directed | |||||
| q 6PM, etc. | Every evening | Mistaken as every 6 hours | Use daily at 6 PM or 6 PM daily | |||||
| IN | Intranasal | Mistaken as IM or IV | Use intranasal | |||||
| IT | Intrathecal | Mistaken as intratracheal, intratumor, intratympanic, or inhalation therapy | Use intrathecal | |||||
| IJ | Injection | Mistaken as IV or intrajugular | Use injection | |||||
| A) | APAP | ||
| B) | IJ | ||
| C) | PRN | ||
| D) | UD |
DANGEROUS ABBREVIATIONS
| Abbreviation | Intended Meaning | Potential Error | Recommendation | |||||
|---|---|---|---|---|---|---|---|---|
| The Joint Commission's "Do Not Use" List | ||||||||
| U, u | Unit | Mistaken for "0" (zero), the number "4" four, or "cc" | Write "unit" | |||||
| IU | International unit | Mistaken for IV (intravenous) or the number "10" (ten) | Write "international unit" | |||||
| qd, QD, q.d., Q.D. | Daily | Mistaken as every other day (qod) or four times daily (qid) | Write "daily" | |||||
| qod, QOD, q.o.d., Q.O.D. | Every other day | Mistaken as daily (qd) or four times daily (qid) | Write "every other day" | |||||
| Trailing zero (X.0 mg) | X mg | Decimal point is missed | Write X mg | |||||
| Lack of leading zero (.X mg) | 0.X mg | Decimal point is missed | Write 0.X mg | |||||
| MS | Morphine sulfate or magnesium sulfate | Confused for the opposite intended | Write "morphine sulfate" | |||||
| MSO4 | Morphine sulfate | Confused for magnesium sulfate | Write "morphine sulfate" | |||||
| MgSO4 | Magnesium sulfate | Confused for morphine sulfate | Write "magnesium sulfate" | |||||
| Examples of Other Abbreviations to Avoid | ||||||||
| µg | Microgram | Mistaken as milligram (mg) | Use mcg | |||||
| > and < | More than and less than |
| Use "more than" or "less than" | |||||
| @ | At | Mistaken as the number "2" | Use "at" | |||||
| cc | Cubic centimeters | Misread as "u" (units) | Use "mL" | |||||
| Apothecary units (e.g., minims, grains) | Varies | Confused with metric units; unfamiliar to some healthcare professionals | Use metric system | |||||
| APAP | Acetaminophen | Not recognized as acetaminophen | Use complete drug name | |||||
| CPZ | Compazine (prochlorperazine) | Mistaken as chlorpromazine | Use complete drug name | |||||
| HCT | Hydrocortisone | Mistaken as hydroCHLOROthiazide | Use complete drug name | |||||
| HCTZ | HydroCHLOROthiazide | Mistaken as hydrocortisone | Use complete drug name | |||||
| MTX | Methotrexate | Mistaken as mitoXANTRONE | Use complete drug name | |||||
| PTU | Propylthiouracil | Mistaken as Purinethol (mercaptopurine) | Use complete drug name | |||||
| SSI | Sliding scale insulin | Mistaken as Strong Solution of Iodine (Lugol's) | Use "sliding scale (insulin)" | |||||
| SSRI | Sliding scale regular insulin | Mistaken as selective serotonin reuptake inhibitor | Spell out "sliding scale (insulin)" | |||||
| TAC | Triamcinolone, tacrolimus |
|
| |||||
| / (slash mark) | Separates two doses | Mistaken as the number 1 (e.g., 25 units/10 units misread as 25 units and 110 units) | Use "and" rather than a slash mark to separate doses | |||||
| Qhs | Nightly at bedtime | Mistaken as qhr (every hour) | Use QHS or qhs for bedtime | |||||
| TIW or tiw | Three times a week | Mistaken as 3 times a day or twice in a week | Use 3 times weekly | |||||
| BIW or biw | Two times a week | Mistaken as 2 times a day | Use 2 times weekly | |||||
| SC, SQ, sq, or sub q | Subcutaneous(ly) |
| Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly) | |||||
| D/C | Discharge or discontinue | Premature discontinuation of medications if D/C (intended to mean discharge) on a medication list has been misinterpreted as discontinued | Use discharge and discontinue or stop | |||||
| AD, AS, AU | Right ear, left ear, each ear | Mistaken as OD, OS, OU (right eye, left eye, each eye) | Use right ear, left ear, each ear | |||||
| OD, OS, OU | Right eye, left eye, each eye | Mistaken as AD, AS, AU (right ear, left ear, each ear) | Use right eye, left eye, each eye | |||||
| UD | As directed (ut dictum) | Mistaken as unit dose (e.g., an order for "dilTIAZem infusion UD" mistakenly administered as a unit [bolus] dose) | Use as directed | |||||
| q 6PM, etc. | Every evening | Mistaken as every 6 hours | Use daily at 6 PM or 6 PM daily | |||||
| IN | Intranasal | Mistaken as IM or IV | Use intranasal | |||||
| IT | Intrathecal | Mistaken as intratracheal, intratumor, intratympanic, or inhalation therapy | Use intrathecal | |||||
| IJ | Injection | Mistaken as IV or intrajugular | Use injection | |||||
| A) | mg | ||
| B) | ODT | ||
| C) | PO | ||
| D) | QD |
DANGEROUS ABBREVIATIONS
| Abbreviation | Intended Meaning | Potential Error | Recommendation | |||||
|---|---|---|---|---|---|---|---|---|
| The Joint Commission's "Do Not Use" List | ||||||||
| U, u | Unit | Mistaken for "0" (zero), the number "4" four, or "cc" | Write "unit" | |||||
| IU | International unit | Mistaken for IV (intravenous) or the number "10" (ten) | Write "international unit" | |||||
| qd, QD, q.d., Q.D. | Daily | Mistaken as every other day (qod) or four times daily (qid) | Write "daily" | |||||
| qod, QOD, q.o.d., Q.O.D. | Every other day | Mistaken as daily (qd) or four times daily (qid) | Write "every other day" | |||||
| Trailing zero (X.0 mg) | X mg | Decimal point is missed | Write X mg | |||||
| Lack of leading zero (.X mg) | 0.X mg | Decimal point is missed | Write 0.X mg | |||||
| MS | Morphine sulfate or magnesium sulfate | Confused for the opposite intended | Write "morphine sulfate" | |||||
| MSO4 | Morphine sulfate | Confused for magnesium sulfate | Write "morphine sulfate" | |||||
| MgSO4 | Magnesium sulfate | Confused for morphine sulfate | Write "magnesium sulfate" | |||||
| Examples of Other Abbreviations to Avoid | ||||||||
| µg | Microgram | Mistaken as milligram (mg) | Use mcg | |||||
| > and < | More than and less than |
| Use "more than" or "less than" | |||||
| @ | At | Mistaken as the number "2" | Use "at" | |||||
| cc | Cubic centimeters | Misread as "u" (units) | Use "mL" | |||||
| Apothecary units (e.g., minims, grains) | Varies | Confused with metric units; unfamiliar to some healthcare professionals | Use metric system | |||||
| APAP | Acetaminophen | Not recognized as acetaminophen | Use complete drug name | |||||
| CPZ | Compazine (prochlorperazine) | Mistaken as chlorpromazine | Use complete drug name | |||||
| HCT | Hydrocortisone | Mistaken as hydroCHLOROthiazide | Use complete drug name | |||||
| HCTZ | HydroCHLOROthiazide | Mistaken as hydrocortisone | Use complete drug name | |||||
| MTX | Methotrexate | Mistaken as mitoXANTRONE | Use complete drug name | |||||
| PTU | Propylthiouracil | Mistaken as Purinethol (mercaptopurine) | Use complete drug name | |||||
| SSI | Sliding scale insulin | Mistaken as Strong Solution of Iodine (Lugol's) | Use "sliding scale (insulin)" | |||||
| SSRI | Sliding scale regular insulin | Mistaken as selective serotonin reuptake inhibitor | Spell out "sliding scale (insulin)" | |||||
| TAC | Triamcinolone, tacrolimus |
|
| |||||
| / (slash mark) | Separates two doses | Mistaken as the number 1 (e.g., 25 units/10 units misread as 25 units and 110 units) | Use "and" rather than a slash mark to separate doses | |||||
| Qhs | Nightly at bedtime | Mistaken as qhr (every hour) | Use QHS or qhs for bedtime | |||||
| TIW or tiw | Three times a week | Mistaken as 3 times a day or twice in a week | Use 3 times weekly | |||||
| BIW or biw | Two times a week | Mistaken as 2 times a day | Use 2 times weekly | |||||
| SC, SQ, sq, or sub q | Subcutaneous(ly) |
| Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly) | |||||
| D/C | Discharge or discontinue | Premature discontinuation of medications if D/C (intended to mean discharge) on a medication list has been misinterpreted as discontinued | Use discharge and discontinue or stop | |||||
| AD, AS, AU | Right ear, left ear, each ear | Mistaken as OD, OS, OU (right eye, left eye, each eye) | Use right ear, left ear, each ear | |||||
| OD, OS, OU | Right eye, left eye, each eye | Mistaken as AD, AS, AU (right ear, left ear, each ear) | Use right eye, left eye, each eye | |||||
| UD | As directed (ut dictum) | Mistaken as unit dose (e.g., an order for "dilTIAZem infusion UD" mistakenly administered as a unit [bolus] dose) | Use as directed | |||||
| q 6PM, etc. | Every evening | Mistaken as every 6 hours | Use daily at 6 PM or 6 PM daily | |||||
| IN | Intranasal | Mistaken as IM or IV | Use intranasal | |||||
| IT | Intrathecal | Mistaken as intratracheal, intratumor, intratympanic, or inhalation therapy | Use intrathecal | |||||
| IJ | Injection | Mistaken as IV or intrajugular | Use injection | |||||
| A) | .5 milligrams | ||
| B) | 0.5 mg | ||
| C) | 500 µg | ||
| D) | 500.0 mcg |
DANGEROUS ABBREVIATIONS
| Abbreviation | Intended Meaning | Potential Error | Recommendation | |||||
|---|---|---|---|---|---|---|---|---|
| The Joint Commission's "Do Not Use" List | ||||||||
| U, u | Unit | Mistaken for "0" (zero), the number "4" four, or "cc" | Write "unit" | |||||
| IU | International unit | Mistaken for IV (intravenous) or the number "10" (ten) | Write "international unit" | |||||
| qd, QD, q.d., Q.D. | Daily | Mistaken as every other day (qod) or four times daily (qid) | Write "daily" | |||||
| qod, QOD, q.o.d., Q.O.D. | Every other day | Mistaken as daily (qd) or four times daily (qid) | Write "every other day" | |||||
| Trailing zero (X.0 mg) | X mg | Decimal point is missed | Write X mg | |||||
| Lack of leading zero (.X mg) | 0.X mg | Decimal point is missed | Write 0.X mg | |||||
| MS | Morphine sulfate or magnesium sulfate | Confused for the opposite intended | Write "morphine sulfate" | |||||
| MSO4 | Morphine sulfate | Confused for magnesium sulfate | Write "morphine sulfate" | |||||
| MgSO4 | Magnesium sulfate | Confused for morphine sulfate | Write "magnesium sulfate" | |||||
| Examples of Other Abbreviations to Avoid | ||||||||
| µg | Microgram | Mistaken as milligram (mg) | Use mcg | |||||
| > and < | More than and less than |
| Use "more than" or "less than" | |||||
| @ | At | Mistaken as the number "2" | Use "at" | |||||
| cc | Cubic centimeters | Misread as "u" (units) | Use "mL" | |||||
| Apothecary units (e.g., minims, grains) | Varies | Confused with metric units; unfamiliar to some healthcare professionals | Use metric system | |||||
| APAP | Acetaminophen | Not recognized as acetaminophen | Use complete drug name | |||||
| CPZ | Compazine (prochlorperazine) | Mistaken as chlorpromazine | Use complete drug name | |||||
| HCT | Hydrocortisone | Mistaken as hydroCHLOROthiazide | Use complete drug name | |||||
| HCTZ | HydroCHLOROthiazide | Mistaken as hydrocortisone | Use complete drug name | |||||
| MTX | Methotrexate | Mistaken as mitoXANTRONE | Use complete drug name | |||||
| PTU | Propylthiouracil | Mistaken as Purinethol (mercaptopurine) | Use complete drug name | |||||
| SSI | Sliding scale insulin | Mistaken as Strong Solution of Iodine (Lugol's) | Use "sliding scale (insulin)" | |||||
| SSRI | Sliding scale regular insulin | Mistaken as selective serotonin reuptake inhibitor | Spell out "sliding scale (insulin)" | |||||
| TAC | Triamcinolone, tacrolimus |
|
| |||||
| / (slash mark) | Separates two doses | Mistaken as the number 1 (e.g., 25 units/10 units misread as 25 units and 110 units) | Use "and" rather than a slash mark to separate doses | |||||
| Qhs | Nightly at bedtime | Mistaken as qhr (every hour) | Use QHS or qhs for bedtime | |||||
| TIW or tiw | Three times a week | Mistaken as 3 times a day or twice in a week | Use 3 times weekly | |||||
| BIW or biw | Two times a week | Mistaken as 2 times a day | Use 2 times weekly | |||||
| SC, SQ, sq, or sub q | Subcutaneous(ly) |
| Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly) | |||||
| D/C | Discharge or discontinue | Premature discontinuation of medications if D/C (intended to mean discharge) on a medication list has been misinterpreted as discontinued | Use discharge and discontinue or stop | |||||
| AD, AS, AU | Right ear, left ear, each ear | Mistaken as OD, OS, OU (right eye, left eye, each eye) | Use right ear, left ear, each ear | |||||
| OD, OS, OU | Right eye, left eye, each eye | Mistaken as AD, AS, AU (right ear, left ear, each ear) | Use right eye, left eye, each eye | |||||
| UD | As directed (ut dictum) | Mistaken as unit dose (e.g., an order for "dilTIAZem infusion UD" mistakenly administered as a unit [bolus] dose) | Use as directed | |||||
| q 6PM, etc. | Every evening | Mistaken as every 6 hours | Use daily at 6 PM or 6 PM daily | |||||
| IN | Intranasal | Mistaken as IM or IV | Use intranasal | |||||
| IT | Intrathecal | Mistaken as intratracheal, intratumor, intratympanic, or inhalation therapy | Use intrathecal | |||||
| IJ | Injection | Mistaken as IV or intrajugular | Use injection | |||||
| A) | Call the prescriber to verify the medication and dose. | ||
| B) | Proceed with filling the prescription for hydrochlorothiazide. | ||
| C) | Fill the prescription for hydrocortisone since it's usually abbreviated "HCT." | ||
| D) | Have a colleague read the prescription and then fill the Rx based on their interpretation. |
Suffixes at the end of drug names such as CD, SR, and XL can increase the risk of errors. There is no standard meaning to suffixes, and the suffixes don't tell you how fast the medication is released or how often it is dosed. Errors that result from the use of suffixes may happen because of confusion about the suffix, not knowing what the suffix means, and lack of standardized meanings across suffixes. This can lead to product mix-ups, prescriptions written with incorrect dosing intervals or frequencies, omission of a suffix, incorrect suffix, etc. There are recommendations that promote the safe use of suffixes. Safety recommendations regarding suffixes include [42]:
Regardless of the prescription format (written, oral, electronic, etc.), prescribers should always indicate the complete proprietary and/or generic drug name, including the suffix when applicable.
Pharmacists should call prescribers to clarify prescriptions where the presence or absence of a suffix doesn't agree with the prescribed dosing schedule.
Patients should be proactively educated about the use and meaning of drug name suffixes.
Medication errors, including near misses, associated with the use of drug-name suffixes should be reported.
Drug products that contain suffixes in the name should be evaluated to determine the potential for errors in all stages of the medication use process.
| A) | Put products that look similar next to each other on the shelf. | ||
| B) | Use abbreviations to prevent mix-ups with sound-alike drugs. | ||
| C) | Document only the generic drug names when taking med histories. | ||
| D) | Include the indication in the Rx directions when provided in the Rx sig. |
There's a lot that can be done to prevent mix-ups with look-alike/sound-alike drug names. Make sure that prescriptions are written clearly and avoid abbreviations. Include both brand and generic names to provide additional clarification. Repeat drug names back to the prescriber when taking a verbal order. It's also helpful if prescribers make sure patients are aware of the reason a medication has been prescribed and include the indication for use on the prescription. For instance, if you receive a prescription for atorvastatin with a sig that says "1TPOHS for cholesterol," you should type up the directions as, "Take 1 tablet by mouth at bedtime for cholesterol." Including the indication will remind the patient what the medication is for, which can be especially important when taking multiple meds. Also think of this as another safety check in the dispensing process. For example, digoxin, a heart medication, can sound similar to levothyroxine, a thyroid medication. So an Rx for digoxin with the sig, "Take 1 tablet by mouth daily for thyroid" is a red flag that something is off.
| A) | Recommend that patients only use OTC branded products. | ||
| B) | Arrange OTC products in alphabetical order instead of therapeutic category. | ||
| C) | Specify ingredients instead of brand names when discussing OTC products. | ||
| D) | Ask the patient to get an Rx for the OTC product to ensure they're getting the right one. |
When discussing an OTC product, specify ingredient instead of brand name to prevent confusion. Ask patients about their intended use of OTC products. Pharmacies can stock OTC products by therapeutic category and use shelf alerts to warn customers of product changes.
| A) | Make sure all the medications you will need are packed in your checked luggage. | ||
| B) | Foreign meds may have a brand name with different ingredients than expected. | ||
| C) | Take all of your medications out of their original containers and organize them into a pillbox. | ||
| D) | Don't worry if you run out while overseas; you'll be able to get the same med at a lower cost. |
Tell patients who travel abroad to carry enough of their meds and a list of their drugs by BOTH generic and brand name. Warn patients who are getting drugs abroad to beware. Although medications may seem less expensive, they may not be getting the intended medication. To find out the ingredients of a foreign drug, check with a drug information center (some colleges or pharmacy have one) or call 800-222-1222 to contact your regional poison control center.
When traveling with medications, patients should be careful not to expose them to extreme temperatures (e.g., in checked baggage or the glove compartment of a car). Having medications in their original labeled prescription containers helps to identify them during security checks and ensures relevant information is readily available if needed.
| A) | Amiodarone | ||
| B) | Lisinopril | ||
| C) | Spironolactone | ||
| D) | Warfarin |
The key is knowing which alerts are important and which are not. Discontinued drugs cause many alerts, but most aren't serious. But be aware of medications that have long durations of action as their effects can last after discontinuation. Interactions with amiodarone, fluoxetine, and monoamine oxidase inhibitors (MAOIs; e.g., phenelzine, tranylcypromine) can occur for two weeks or longer after the med is stopped. Be careful when cytochrome P450 (CYP) enzyme inhibitors or inducers are discontinued. These CYP enzyme inhibitors or inducers can increase or decrease the activity of some drugs (i.e., substrates). Any substrate that is continued after the discontinuation of CYP enzyme inhibitors or inducers may need a dose adjustment.
| A) | Fluoxetine | ||
| B) | Losartan | ||
| C) | Simvastatin | ||
| D) | Topiramate |
Continue to pay attention to the "big" drug interactions:
Potassium-sparing diuretics (e.g., spironolactone, eplerenone) with ACE inhibitors (lisinopril, enalapril, etc.) or ARBs (candesartan, losartan, etc.) – risk of high potassium (hyperkalemia)
Trimethoprim/sulfamethoxazole (TMP/SMX) with meds that can increase potassium levels (e.g., ACE inhibitors, ARBs, potassium-sparing diuretics) – risk of hyperkalemia
TMP/SMX with warfarin – risk of bleeding due to increased activity of warfarin
Clarithromycin with digoxin – risk of increased side effects of digoxin (heart rhythm disorders, confusion, etc.)
Clarithromycin with some statins – risk of increased side effects of the statin (muscle damage)
Combined hormonal oral contraceptives with certain enzyme inducers (carbamazepine, fosamprenavir, phenytoin, topiramate, etc.) – may decrease the efficacy of the oral contraceptives [54]
| A) | Read back the drug name and any other info only if it is questionable. | ||
| B) | Repeat the order back only if you are not clear that you heard the order correctly. | ||
| C) | Read all verbal orders back and obtain confirmation that the order is correct. | ||
| D) | Repeat a verbal order to a pharmacy staff member to see if it makes sense to them. |
Ineffective communication is a frequently cited cause of serious patient harm. Verbal prescription orders are not recommended, and it is suggested that they be reserved for urgent situations when written or electronic prescribing is not practical [56]. In the hospital setting, many institutions have created policies to prohibit any verbal orders. In pharmacies, the "verbal order read-back" is essential for all phone orders, verbal orders, and test results that must be taken verbally. This practice helps improve the effectiveness of communication, ensuring that important information is relayed in an accurate, complete, and unambiguous manner [57].
Verbal order read-back has been a National Patient Safety Goal in prior years and is a required practice of some healthcare organizations. Order read-back requires that the recipient first write down the complete order or enter the information into the computer system. The recipient of the information then reads back the order or test result to the individual who gave the order. The recipient must seek and receive confirmation from the individual who gave the order or test result that the information is correct [60].
| A) | A clerk provides a patient with written patient education. | ||
| B) | A patient explains to the pharmacist how and why they are taking their medications. | ||
| C) | A technician directs a patient to ask their prescriber about how to use their medication. | ||
| D) | A pharmacist tells a patient how to use an inhaler and tells them to take it home to practice. |
Use a "teach back" approach. Have patients tell you how and why they are taking their meds. Tailoring drug regimens to the patient's lifestyle helps. For example, check for less expensive generics, meds with fewer doses, or a different side effect profile. When provided, put the diagnosis on the Rx label (this is required if the indication is included as part of the Rx sig), encourage use of a pillbox, give private counseling, and use refill reminder programs. Give patients positive feedback on progress, and encourage them to monitor their blood pressure, blood glucose, etc. Ask open ended questions, such as "What problems have you had with your medications?"
| A) | Antivirals | ||
| B) | NSAIDs | ||
| C) | Opioids | ||
| D) | SSRIs |
ISMP maintains a list of drugs and drug classes which have the highest risk of causing devastating consequences to patients if used inappropriately. These medications may need to have special safeguards in place, such as double checks, to reduce the risk of errors. Many pharmacies and institutions create their own list, usually based on the ISMP list plus any of their own near misses and reported errors. Lists of high-alert meds may include, but are not limited to [62,63]:
Antithrombotics used to thin the blood (enoxaparin, warfarin, etc.)
Chemotherapy drugs
Injectable electrolytes (potassium chloride, potassium phosphate, hypertonic sodium chloride, magnesium sulfate, etc.)
Insulin
Methotrexate
Opioids (fentanyl, hydrocodone, etc.)
Sedative agents, IV (lorazepam, midazolam, etc.)
Sulfonylurea hypoglycemics for diabetes (glipizide, glyburide, etc.)
| A) | Encourage dialogue by asking open-ended questions. | ||
| B) | Minimize verbal teaching since most patients have low health literacy. | ||
| C) | Wait for the patient to initiate questions before sharing any information. | ||
| D) | Keep information shared to the minimum necessary since an informed patient can impede med safety. |
Be aware of best practices to prevent dispensing errors. Adjust your practice so these activities are second nature; make them a habit when you are dispensing prescriptions [13]:
Pharmacists should not dispense an unfamiliar drug until performing appropriate research regarding its uses, contraindications, and hazards.
Clarify with the patient and/or prescriber the patient's clinical history and diagnosis to ensure appropriate use of the prescribed drug.
Patient profiles should be current and contain enough information for pharmacists to assess appropriateness of medication therapy. Make notes and add dated information to help with future patient interactions and prescriptions. This helps provide clear information to all staff for future encounters.
Follow all pharmacy protocols and don't take shortcuts when entering a drug order into the computer system. Use only approved sigs.
Double-check all auto-populated information from an electronic prescription since information may not be transcribed completely or accurately.
Make sure Rx directions are clear, correct, and complete; include all directions and information for the patient from the sig and e-Rx notes on the label, such as indications, whether a drug should be used as needed ("PRN"), or durations of therapy (antibiotic courses, etc.).
Don't automatically override any alerts without appropriate verification.
Pharmacy technicians should alert the pharmacist (who may need to contact the prescriber) regarding any questionable prescription or alerts prompted by the dispensing system.
Ensure all prescriptions are checked prior to dispensing. Verify each prescription against the original order.
Pharmacists should counsel patients when dispensing medications. This is an important safety check for correct dispensing and ensuring patient comprehension. Ask open-ended questions of the patient to engage them in conversation. Discourage having the pharmacy technician simply ask patients, "Do you have any questions for the pharmacist?" Patients often don't have or can't think of questions on the spot. Asking the patient open-ended questions may help uncover any problems or issues.
Work areas and workflow should be well designed to help prevent errors, such as adequate lighting, low noise, few distractions, etc.
Drugs should be organized or otherwise differentiated to reduce confusion between similar names, labels, or strengths. Consider using color-coded baskets, shelf dividers, signs, notes, etc., to draw attention to high-risk medications and commonly confused drugs.
Pharmacies should have and follow dispensing policies and procedures. This creates a standard of practice for all staff to follow. These should be reviewed if a near miss or error occurs as it provides an opportunity to revise procedures, when appropriate, to prevent future errors.
| A) | Fill the discharge Rxs and deactivate any Rxs that were used prior to admission. | ||
| B) | Refill all Rxs that were taken prior to admission in addition to filling the discharge Rxs. | ||
| C) | Put any discharge Rxs with the same indication as an Rx used prior to admission on hold. | ||
| D) | Go through the Rxs taken prior to admission and compare them to the discharge Rxs. |
Inaccuracies don't just occur with hospital admissions. It has been found that up to 76% of patients' discharge summaries may include errors [76]. These types of medication errors can be reduced by 70% when pharmacists evaluate medications at admission, transfer, and discharge [83]. Pharmacists can be alert for patients who are at high risk or on complex medication regimens for follow-up by their local pharmacist [6]. On discharge, watch for medications that may be duplicates in therapy. As previously mentioned, patients may have been switched from a home medication to a formulary medication on admission. An error can occur if upon discharge, a prescription is given for both the original home med plus the hospital med. For example, a hospital may stock only one proton pump inhibitor (PPI; e.g., lansoprazole, pantoprazole). If a patient takes lansoprazole at home, they may be switched to pantoprazole on admission if that is the formulary PPI. In this example, it's important to make sure that this patient does not get prescriptions for both lansoprazole and pantoprazole on discharge. Any aspect of medication use that is unclear, confusing, or contradictory should be addressed and information uncovered until the issue is resolved.
| A) | Taking care of the patient | ||
| B) | Saying it was not the pharmacy's fault | ||
| C) | Reviewing malpractice insurance terms | ||
| D) | Assessing how to prevent the error in the future |
The first step in dealing with a medication error is to take care of the patient [86]. This is the right thing to do. Get the details of the situation by asking the patient important questions, such as why they think an error occurred, whether the medication was taken, how much of the medication was taken, and how they are feeling. Pharmacists should contact the patient's other providers to explain the situation and discuss the best course of action. Pharmacists should try to speak with each provider directly, providing patient details or status, facts about the situation, and what has been done so far.
| A) | Report only errors that've reached the patient, not near misses. | ||
| B) | Include all details of the error in the patient's medication profile. | ||
| C) | Use a separate quality assurance document or system to document the error. | ||
| D) | Give preference to national reporting systems over systems provided by your organization's PSO. |
One caveat is to make sure error reports are written as separate quality assurance documents and are not inserted as a part of the patient drug profile or medical record. This is important from a legal perspective. If an error report is included as part of a patient drug profile, it becomes a part of the patient's medical record. Medical records can be subpoenaed by a court. In most instances, separately written error reports are provided with some protection under the law. This may make it more comfortable for an organization to record errors in the hopes of improving quality assurance without fear of having the documentation used against the organization in a legal matter. Again, error records are meant to be used as learning tools, not punishment.
| A) | Root cause analysis | ||
| B) | Risk management analysis | ||
| C) | Critical event and error analysis | ||
| D) | Failure mode and effects analysis |
Failure mode and effects analysis (FMEA) is another process that can be used for examining medication errors [93]. FMEA is a proactive process, rather than a reactive one; it differs from root cause analysis in that it can be used before an error happens, to identify points of potential failure and what the effects would be. Failure mode and effects analysis provides an opportunity to prevent errors with potentially significant consequences, or to minimize their consequences. Like root cause analysis, failure mode and effects analysis requires multidisciplinary resources [13].