Introduction
More than 7000 pharmacists gathered
in Atlanta, Georgia, for the
American Pharmacists Association (APhA)
2007 Annual Meeting to explore
new challenges and the latest
advances in pharmacy. Among the more than
80 programs presented were
several sessions that dealt with reducing
medication errors and
adverse events, a topic that has received
widespread media attention
In addition, the author of a critically acclaimed book
on
drug errors was on-site to discuss his book and to autograph copies
for
attendees. Michael R. Cohen, RPh, MS, ScD, DPS, is President of the
Institute
for Safe Medication Practices (ISMP) and author of Medication
Errors,
which was published by the APhA
Conference participants
learned about common
medication errors, steps to avoid or eliminate
them, strategies to
communicate effectively with prescribers, and
ways to recognize and
reduce stressful situations in the pharmacy
workplace that may
contribute to medication errors
"Top 10" Medications Involved in
Adverse Events
The
Institute of Medicine (IOM) published findings in 1999 on the
quality
of healthcare in America. That report, "To Err Is Human:
Building a
Safer Health System," concluded that as many as 7000
Americans die
from medication errors each year
In July 2006, the IOM released a
new report,
"Preventing Medication Errors," stating that the
frequency of medication
errors and related injuries was still a
serious concern
A common question that arises is: " What
drugs are most often involved in medication
errors? " Matthew
Grissinger, RPh, FASCP, is a medication
safety analyst with ISMP, the
nation's oldest voluntary drug error
reporting program, located in
Huntingdon, Pennsylvania. His session
on "The Top 10 Adverse Drug
Reactions and Medication Errors" drew an
audience that filled the
meeting hall
Grissinger first
referred to a study that identified
the 10 drugs most commonly
implicated in adverse events requiring
treatment in a hospital
emergency department (ED).The study also
documented the frequency
with which each of the 10 drugs was involved
Insulin (8%)i
Anticoagulants (6.2%)i
Amoxicillin (s) (4.3%)i
Aspirin (2.5%)i
Trimethoprim-sulfamethoxazole (2.2%)i
Hydrocodone/acetaminophen
(2.2%)i
Ibuprofen
(2.1%)i
Acetaminophen
(1.8%)i
Cephalexin
(1.6%)i
Penicillin
(1.3%)i
Unintentional
overdoses made up 40% of these ED
visits, representing the
most prevalent mechanism of injury by far.
Other mechanisms included
side effects and allergic reactions
Some of
the drugs on this list are especially common
(eg, hydrocodone and
amoxicillin), so the sheer volume of prescriptions
written is a
major factor
The elderly also play a key role in this
issue, as
they account for 34% of all written prescriptions. The
average number of
prescriptions for an elderly person in the United
States in 2000 was
28.5 per year. That number is estimated to reach
38.5 by the year 2010.
Almost a quarter million seniors are
hospitalized every year due to
reactions between prescription and
over-the-counter (OTC) medications
Common misuses that
lead to adverse drug events are
taking incorrect doses,
taking doses at the wrong times, forgetting
to take
doses, or stopping the medication too soon (all
nonadherence
issues). An example of commonly misused medications can be
seen with
arthritis therapies
Seventy million Americans suffer from
arthritis and
joint pain, which translates into 30 million people
taking nonsteroidal
anti-inflammatory drugs, either prescription or
OTC. Misuse of these
drugs leads to 103,000 hospitalizations and
16,000 deaths per year.
Unnecessary use of nonsteroidal
anti-inflammatory drugs also
increases avoidable side effects,
such as dyspepsia, peptic ulcer, and
gastrointestinal bleeding
Another high-volume prescription class is the antibiotics.
This group represents significant inappropriate prescribing:
Twenty-three
million antibiotic prescriptions are written for colds,
bronchitis,
and upper respiratory infections each year, Grissinger said,
despite the fact that antibiotics don't kill viruses
Top 10 Medications Involved in Drug
Errors
A
somewhat different top 10 list identifies medications that are most
commonly
misused or mishandled in some way by healthcare professionals.
This
list is based on information from the United States Pharmacopoeia
(USP), which maintains a database of
medication
errors that are reported anonymously. The figures represent
drug
errors associated with acute hospital care
Insulin (4% of all medication errors
in 2005)i
Morphine (2.3%)i
Potassium chloride (2.2%)i
Albuterol (1.8%)i
Heparin (1.7%)i
Vancomycin (1.6%)i
Cefazolin (1.6%)i
Acetaminophen (1.6%)i
Warfarin (1.4%)i
Furosemide (1.4%)i
Hospitals and healthcare
systems use the USP database
to track medication errors and identify
trends. Drug errors are defined
as unintentional acts committed by
healthcare providers involving
medications. Grissinger noted that
comparable data are unavailable for
outpatient care
The
number 1 error-prone medication is insulin. In
fact, a 1998 ISMP study found that 11% of
all serious medication
errors involve insulin misadministration. Errors
include mixing up
products with similar packaging (look-alike
products); confusing
generic listings on computer databases; similarity
in names (eg,
Humalog and Humulin); and most importantly, confusing the
abbreviation
"u" for units with the number 0. ISMP reports that these
errors
have been occurring for over 30 years
The second drug on
this list is morphine,
which can be
extrapolated to include all opioids, Grissinger said.
Similar names
for some of these drugs often cause confusion, such
as
Avinza and Evista
Morphine and
hydromorphone
Oxycontin and MS Contin
Hydrocodone and oxycodone
Oxycodone
and codeine
In the community pharmacy, these drugs
often are
stacked close together in a locked area, and many have
similar
packaging, making it easy to grab the wrong one when
dispensing. Another
common mistake is mixing up oxycodone with
oxycodone ER (extended
release), especially in handheld device order
entry
Morphine oral solutions cause many problems because
of
the multiple concentrations that are available, all stored
close
to each other. For example, it would be easy to confuse "mL"
with "mg";
using 5 mL of morphine 20 mg/mL (100 mg) instead of the
prescribed 5 mg
(0.25 mL) would lead to overdosing the patient.
Alternatively, an
intended dose of 1 mL of morphine 20 mg/mL (20 mg)
might be given as 1
mL of 10 mg/5 mL (2 mg), thus underdosing the
patient. Grissinger also
reported a case in which Avinza (morphine
ER caps) 30 mg was
misinterpreted and dispensed as "qid" (4 times
daily) instead of "qd"
(once daily), causing a near-fatal overdose
Acetaminophen is another drug
on the
error list that causes many problems. It is available in many
different
strengths, and various measuring devices are available for
dispensing
it. In addition, it is found in many combination medications,
both
prescription and OTC. Prescription labels of combination products
with
acetaminophen can be very confusing for the patient. For example,
hydrocodone
10/650 has 650 mg of acetaminophen, but many patients would
not
know how to interpret that
Grissinger reminded the audience that
acetaminophen
can be toxic, even though it is sold OTC. A recent
study showed that
acetaminophen-induced liver toxicity accounts for
more than 40% of US
cases of acute liver failure
Antibiotics are the next big
group of drugs
associated with medication errors. As with opioids, the
liquid dose
concentrations increase the risk for mistakes. Confusion
over
measurements in "mL" vs "tsp" (teaspoons) can cause a 5-fold
overdose
or underdose if undetected. In one case, for example,
azithromycin
suspension was dispensed with directions to take 2.5 tsp
daily
(*****alent to 12.5 mL) instead of the intended 2.5 mL daily,
Grissinger
reported. The entire *******s of the bottle were administered
according to the labeled instructions, and the child developed diarrhea
Reconstituting antibiotics can also be problematic.
Pharmacists
have mistakenly reconstituted antibiotic suspensions with
alcohol
instead of distilled water
System Errors May Interfere With
Individual Efforts
Most healthcare professionals have learned the "5
rights" of safe
medication use: the right patient, the right drug,
the right time, the
right dose, and the right route of
administration
However, in his book Medication Errors, Michael
Cohen
wrote that these "rights" focus on individual performance and
can
overlook system errors. Examples of system errors are poor
lighting,
inadequate staffing, handwritten orders, doses with
trailing zeros, and
ambiguous drug labels. All of these can prevent
healthcare professionals
from verifying the 5 rights
Experts
at ISMP have identified 10 key "system"
elements that most
influence medication use, reported Donna Horn, RPh,
DPh, ISMP
Director, Patient Safety - Community Pharmacy. Systems factors
play a
major role in increasing the likelihood that an individual will
make
an error
Deficiencies in any of these system
elements
can lead to medication errors
Patient information (age,
weight, allergies,
diagnoses, and pregnancy status)i
Drug information (up-to-date information
readily
available)i
Communication
(collaborative teamwork between all
healthcare members and the
patient)i
Drug labeling, packaging,
and nomenclature (limit
look-alike and sound-alike drug names,
confusing packaging)i
Drug
standardization, storage, and distribution
(restricting access to
high-alert drugs)i
Medication
delivery device acquisition, use, and
monitoring
Environmental
factors (poor lighting, cluttered work
spaces, noise,
interruptions, nonstop activity, and deficient staffing)i
Staff competency and education
Patient
education; and
Quality processes and risk management (systems
are
needed for identifying, reporting, analyzing, and reducing the
risk for
medication errors with a nonpunitive culture of safety)i
When an error occurs, it is
tempting to blame
individuals, Horn said. A "systems approach,"
however, looks at the
whole system rather than individual errors.
For instance, failures in
the design or implementation of systems
can lead to excessive reliance
on memory, lack of standardization,
inadequate access to information,
and poor work schedules. Thus,
with a systems approach, accountability
is expanded to include
anyone who had any influence over the error,
setting the stage for
broader solutions
How Can We Prevent
Medication
Errors?i
Nearly
half of all adverse drug events have some form
of "preventability,"
and many do not represent errors of commission but,
rather, errors
of omission. This implies a failure on the part of
someone
(pharmacist, physician, patient, or the interactions between
these
groups) to detect certain factors that most likely led to the
adverse
event
These factors include
Failure
to detect a disease state contraindication to the drug therapy
Failure
to detect a significant drug interaction
Failure to detect a
significant drug allergy
Failure to prescribe the correct dose
for a specific
patient
Failure to monitor drugs with narrow
therapeutic
indexes; and
Patient knowledge deficits
Many of these can be avoided by spending a few minutes
counseling the prescriber and/or the patient. Communication is key,
Horn
said. Barriers to effective communication include illegible
handwriting, abbreviations, verbal orders,
ambiguous orders, and
fax or ePrescribing problems
When communicating with
prescribers, pharmacists should identify the
issues clearly and
concisely, said Marialice Bennett, RPh, FAPhA,
Professor and
Pharmacy Director of the University Health Connection at
Ohio State
University in Columbus, Ohio. She offered these
suggestions for such discussions
Outline the specifics of
the problem
Keep focused on the patient
Provide
possible solutions
Ask for prescriber feedback
Document
the final decision
Conflict can lead to poor communication,
which can
hinder the discovery of medication errors, she said.
Conflicting
opinions about patient care should be handled
objectively and
professionally. The ISMP recommends that healthcare
organizations create
a code of conduct that encourages behaviors
supportive of team
cohesion, staff morale, and sense of self-worth
and safety
Managing Stress in a Workplace Full of Risks
Pharmacy
work can be highly stressful, and pharmacists who are under
extreme
stress are at risk for more errors, said Henry Cobb, PhD, MD,
BS,
CDM, Clinical Associate Professor, University of Georgia College of
Pharmacy,
Athens, Georgia. Pharmacists need to identify their own
personal
stress triggers and anticipate their responses to stress. He presented 5 questions that could be used for such
self-analysis
How do you know whether stress is a problem for you?i
What is causing most of your stress?i
Is your supervisor aware of the problem?i
How do you deal with stress?i
What can you do to reduce the impact
of stress?i
Cobb described 3 ways
that most workers deal with
stress on the job. The active-cognitive
person draws on past experience,
taking one thing at a time. He or
she considers several alternatives,
looking for the positive side,
and is able to step back and be
objective. The active-behavioral
person finds out more about the
situation and takes positive action
He or she may talk with a friend or spouse, exercise
more, or
talk with a professional in order to find a solution. The
person who
practices avoidance keeps feelings to himself or herself,
prepares
for the worst, takes out frustrations on others, and eats or
smokes
more to reduce tension
Identifying the phases of stress can be
helpful. Phase
1, or the warning phase, includes vague anxiety,
depression, and
apathy. Phase 2, or mild stress, includes sleep
disturbances, muscle
aches, and irritability. Entrenched stress, or
phase 3, includes alcohol
abuse, depression, ulcers, withdrawal, and
marital discord. Phase 4, or
severe stress, includes asthma, heart
problems, severe depression,
violence (or suicide), paranoia, and
uncontrolled anger. It is important
to note that professional help
is needed for phases 3 and 4
To reduce stress
on the job, Cobb
presented this list of quick strategies
Discontinue
caffeine
Engage in regular exercise (30 minutes 3 times weekly)i
Practice relaxation-breathing exercises
(20 minutes 2
times weekly)i
Get
adequate sleep (try going to bed 30 minutes
earlier than usual)i
Nurture your leisure time, engage in
hobbiesi
Set realistic expectations and avoid perfection
Reframe
your outlook to be optimistic, not pessimistic
Eat right
Maintain a sense of humor
Talk and vent
Write down
your thoughts
Avoid unhealthy habits (such as alcohol)i
Set limits (learn to say "no")i
Get help from a professional
In
some cases, however, a person who is in a job that
does not match
his or her personality and preferences may need to switch
to another
role or job, Cobb added. That may be a much better
stress-reduction
technique than any other
References
Kohn K, Corrigan JM,
Donaldson MS. To Err Is Human:
Building a Safer Health System.
Washington, DC: National Academy of
Sciences, National Academy
Press; 2000
Committee on Identifying and Preventing
Medication Errors.
Board on Health Care Services. Institute of Medicine
of the National
Academies
In: Aspden P, Wolcott J, Bootman JL,
Cronenwett LR, eds.
Preventing Medication Errors: Quality Chasm Series.
Washington, DC:
The National Academies Press; 2006
Grissinger M. Top 10
adverse drug
reactions and medication errors. Program and abstracts
of the American
Pharmacists Association 2007 Annual Meeting; March
16-19, 2007; Atlanta,
Georgia
Budnitz DS, Pollock DA, Weidenbach KN,
Mendelsohn
AB, Schroeder TJ, Annest JL. National surveillance of
emergency
department visits for outpatient adverse drug events. JAMA.
2006;296:1858-1866
United States
Pharmacopeia Web site.
Available at: http://www.usp.org/ Accessed April
27,
2007
Institute
for Safe Medication Practices
(ISMP). ISMP action agenda: Oct-Dec
1998. ISMP Medication Safety Alert!
Available at: http://www.ismp.org/Newsletter
s/default.asp
Accessed April 1, 2007
Larson AM, Polson J, Fontana RJ, et al;
Acute
Liver Failure Study Group
Acetaminophen-induced acute liver
failure:
results of a United States multicenter, prospective study.
Hepatology.
2005;42:1364-1372
Cohen M, ed. Medication Errors. 2nd ed.
Washington, DC: American Pharmacists Association; 2007:5-36
Horn D. Top 10
adverse drug reactions
and medication errors. Program and abstracts
of the American Pharmacists
Association 2007 Annual Meeting; March
16-19, 2007; Atlanta, Georgia
Bennett M. Communicating drug therapy
recommendations
to prescribers. Program and abstracts of the American
Pharmacists
Association 2007 Annual Meeting; March 16-19, 2007; Atlanta,
Georgia
Cobb H. Dealing
with stress:
decompression strategies for pharmacists
Program and abstracts of
the American
Pharmacists Association 2007 Annual Meeting; March
16-19, 2007; Atlanta,
Georgia
منقووول
الموضوع : The Top 10 Drug Errors and How to Prevent Them المصدر :منتديات تقى الإسلامية الكاتب: El Helalya
