10_medication_errors.md

Medication Errors

Question	Options	Pre-response	Reading	Final
Not error	Forgetting GTN on admission coamox in pen allergy unlicensed missed vanc level 200mg lithium vs 400mg dispensed	unlicensed	unlicensed	unlicensed
% of adrs as errors		5-10%	10-20%	10-20 %
active failure	communication issues confusing similar drug names lack of training/supervision staffing workload	training	confusing drug name	confusing drug name
dose		5 g	5 g	5 g
medications errors		All of the above	All of above	Trust&NRLS&Patient
Human Error Theory	Action/Rule Knowledge/Action Knowledge/Memory Knowledge/Rule Memory/Rule	Knowledge/Rule	Knowledge/Rule	Knowledge/Rule
blood results	Violation Slip Lapse Mistake	Lapse	Lapse	lapse
statements correct	Class 3 within 48 hours MSO at all organisations Electronic prescribing prevents all errors Slips and Lapses can be trained out Paed dosing errors 10 fold over or under	MSO at all		paed doses
written out in full	grams IV mg sc units	units	units
deliberate oral liqu iv	violation	violation	violation	violation

Learning Outcomes

• Define medication errors, including subtypes.
• Identify individual and systems factors that can lead to error.
• Describe the role of the Medicines and Healthcare Products Regulatory Agency (MHRA) and NHS England in the provision of information to healthcare practitioners on the use of medicines.
• Describe how medication errors are reported.
• Describe the role and impact of electronic prescribing.

Key Points

• Medication errors represent a significant burden of harm for patients and the NHS.
• Good doctors will make bad mistakes.
• Many errors are caused by slips and lapses, which cannot be prevented by further training, only if systems are made safer.
• Mistakes are caused by lack of knowledge and can be made less likely through education and training.
• Prescribers need to be open and honest when they make an error.
• The National Reporting and Learning System (NRLS) is responsible for managing and analysing reports of medication errors.

Definitions

Term	Definition
Treatment Process	Starts after the decision to adopt treatment for symptoms or their causes, or to investigate or prevent disease or physiological changes (and so includes not only therapeutic drugs but also, for instance, oral contraceptives, hormones used in replacement therapy, and radiographic contrast media). It includes the prescribing, transcribing (when relevant), manufacturing or compounding, dispensing and administration of a drug. It also includes the monitoring of therapy, because faulty monitoring can lead to a failure to alter therapy when required, or to an erroneous alteration.
Failure	process has fallen below some attainable standard.

Stage	Explanation
Prescribing errors	failure to order the right drug at the right dose at the right frequency for the right patient.
Dispensing errors	failure to supply the right drug at the right dose at the right frequency for the right patient.
Preparation errors	failure to prepare the right drug at the right dose for the right patient.
Administration errors	failure to administer the right drug at the right dose by the appropriate route and method for the right patient.
Monitoring errors	failure to check the administration and effect of a medicine.

Human Error Theory

Classification	Explanation	Example
Mistake	Error in formulating a plan of action Action was executed correctly but the plan was wrong	Prescribing verapamil even though patient on a beta-blocker, unknowing of interaction
Slip	One or more step is executed incorrectly	Promazine vs Promethazine
Lapse	One or more step is omitted	Distracted and forgetting to do something
Violations	Deliberate - although perhaps not reprehensible - deviation from regulated codes of practices or procedures	Writing brand name instead of generic

Mistakes

Action	Description
Knowledge-based	Require conscious analytic processes and stored knowledge in novel or unfamiliar situations where low-level rules are not appropriate. They refer to what is typically thought of as 'analytic thought'.
Rule-based	Involve the conscious application of specific rules to familiar situations.

Human Error

Systems based approach

Factor	Description	Example
Active failures	Unsafe acts or omissions that are as a result of error or violations	Confusing similar sounding drug names (e.g. prescribing clotrimazole instead of co-trimoxazole) Intending to prescribe a dose of 100 mg but writing 200 mg instead
Latent conditions	Provide the error-producing conditions in which unsafe acts occur and can create long-lasting holes or weaknesses in the defences. They may lie dormant in a system for some time before they are combined with active failures to create an opportunity for error.	Workload Staffing levels Lack of training or supervision Communication problems between healthcare staff Deficiencies in the design of technology