Question

How should medication errors be addressed at each step of the eMAR process? Prescribing, Transcribing, Dispensing and Administration?

Answer 1

A Medication Administration Record , commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical chart.In each steps the errors has to be addressed.

Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease.

• Education, to be taken as often as possible (a repeat prescription—learning should be lifelong).

• Special study modules for graduates and undergraduates, to be taken as required.

• Proper assessment: in the final undergraduate examination, to be taken once or twice; in postgraduate appraisal, to be taken occasionally; this could be linked to a licence to prescribe.

• A national prescription form for hospitals, to be applied uniformly and used as a training tool.

• ℞ Guidelines and computerized prescribing systems, to be taken if indicated (their roles and proper implementation are not yet clear).

Transcription error is a specific type of medication errors and is due to data entry error that is commonly made by the human operators.

Transcription, the transfer of information from an order sheet to nursing documentation forms, is a source of many medication errors. Contributing factors include incomplete or illegible prescriber orders; incomplete or illegible nurse handwriting; use of abbreviations; and lack of familiarity with drug names. In addition to errors associated with transcribing the drug name,there is also opportunity for errors when transcribing the dose, route or frequency. Preparing amedication administration record (MAR) in an environment that is noisy or poorly lit can also contribute to errors.

What can you do to minimize the opportunity for error?
• Clarify the order before the prescriber leaves the unit.
• Contact the prescriber if the order is not legible.
• Do not process incomplete orders. Orders must contain the following information: drug
name, dose, route, dosage form and frequency of administration.
• Minimize the use of abbreviations and certainly avoid the use of unapproved abbreviations
on the MAR.
• Never use the letter 'U' as an abbreviation for units.
• Use a leading zero before a decimal.
• Do not use a trailing zero after the decimal.
• Include indications whenever possible.
• Check your own handwriting: is it legible? If not, think about printing using block letters.
• Complete the transcription process in a quiet area well lit area, away from distractions. If you are transcribing orders in a busy environment, there is the likelihood that you may make an error.
• Implement a system to check the medication administration record document against active orders whether the MAR is manually or computer generated.
• Implement a second check system for the transcription.

Dispensing errors committed by individuals are often the result of error-prone systems and processes. Therefore, the main strategy to reduce dispensing errors is to implement a system oriented approach rather than a punitive approach targeted at an individual. The following is a list of strategies for minimizing dispensing errors:

1. Ensure correct entry of the prescription.
Transcription errors (eg, omissions, inaccuracies) account for ~15% of all dispensing errors. These errors can be reduced by consistently using reliable methods to verify patient identity while entering the prescription into the computer. The Joint Commission requires that at least 2 patient identifiers be used for administering medications in a hospital setting. This strategy helps prevent medication errors due to sound-alike, look-alike names. At this point in the process, it is also useful to have information about the patient, such as the age of the patient, allergies, concomitant medications, contraindications, therapeutic duplications, and the like.

2. Confirm that the prescription is correct and complete.
Pharmacists’ “second guessing” of illegible and/or ambiguous prescriptions, nonstandard abbreviations, acronyms, decimals, and call-in prescriptions are frequently associated with medication errors. Whenever in question, it is important to call the prescriber to clarify any uncertainties or doubts regarding the prescription. Clarification obtained from the physician should be promptly documented. All verbal prescriptions should be immediately transcribed to a blank prescription pad and read back to the caller to ensure that the prescription has been transcribed correctly.

3. Beware of look-alike, soundalike drugs.
Similar drug names account for one third of medication errors. These types of errors are attributed to confirmation bias—a tendency to interpret information in a way that confirms one’s preconceptions and avoids information and interpretations that contradict prior beliefs. As an example, a new, unfamiliar drug may be read as an older, more familiar one. Some of these errors can be fatal (eg, prescribing methadone instead of methylphenidate to an 8-year-old child). Such errors can be reduced by placing reminders on the stock bottle or in the computer system to alert staff about these commonly confused drug names.9

4. Be careful with zeros and abbreviations.
Misplaced zeros, decimal points, and faulty units are common causes of medication errors due to misinterpretation. A transcription or interpretation error involving a zero or a decimal point means that the patient may receive at least 10 times more medication than indicated, which can result in serious consequences (eg, levothyroxine, warfarin).These errors may be prevented by using computer alerts or by stocking a single strength of the medication in the pharmacy. These errors may be detected when reviewing the label directions during patient counseling. The Institute for Safe Medication Practices (ISMP) offers a list of error-prone abbreviations, symbols, and dose designations (a brief list of common dispensing errors is given in the Table). Being familiar with this type of information may also help prevent dispensing errors.

5. Organize the workplace. Organizing work space, work environment, and workflow has been shown to markedly reduce dispensing errors. Proper lighting, adequate counter space, and comfortable temperature and humidity can help facilitate a smooth flow from one task to the next, thus reducing the chances of dispensing errors. Developing a routine for entering, filling, and checking prescriptions will help in organizing the flow of work. In addition, working with one drug product at a time and affixing the label to the patient’s prescription container before working on the next prescription will help prevent mix-ups. It is also important not to leave any drug containers unlabeled.

6. Reduce distraction when possible.
Multitasking and distraction during work is the leading cause of dispensing errors. Automatic-refill requests can reduce some of the distractions and thereby reduce dispensing errors. Also, having pharmacy technicians assist the pharmacists by performing routine functions will help minimize distractions. Although the extent to which distraction at work contributes to cognitive error is unclear, recent studies suggest that perception of dispensing errors by pharmacists is influenced by factors such as design of workflow, window services, and automatic dispensing. It must therefore be the goal of each pharmacy to improve the internal environment, even at the cost of patient convenience, in order to reduce medication errors.

7. Focus on reducing stress and balancing heavy workloads.
Workload increase is often cited as a contributing factor in dispensing errors. Sufficient staffing and appropriate workload will help reduce errors. Regular breaks and time off for meal breaks may help reduce some of the dispensing errors. Sharing responsibilities by clearly assigning duties to the staff will help them understand the expectations of the flow of work and may ultimately aid in reducing workplace stress, and, therefore, reduce medication errors.

8. Take the time to store drugs properly.
One way to avoid mix-ups among lookalike drugs is to store them away from each other in the medication storage area. Medication bottles should be properly organized with labels facing forward. It is also a good idea to routinely check all medications on the shelves and discard any expired medications. Use of storage bins, cabinets, or drawers can result in misplacement of look-alike drugs. It is also advisable to lock up or sequester drugs with high potential of causing errors.

9. Thoroughly check all prescriptions.
Repeated checking and counterchecking is an important strategy to minimize dispensing errors. Comparing the written prescription with the product that appears in the computer, with the label being printed, and with the medication that is being filled will help reduce errors. Confirmation bias and preconceived notions makes self-checking a poor method to reduce errors. Whenever possible, it is advisable to have the rechecking done by another person, typically a pharmacist. If this is not possible, delayed self-checking rather than continuous self-checking is an alternate strategy. A delayed verification will allow the pharmacist to study the prescription from a fresh perspective, which will help in identifying the error that may not have caught his/her attention the first time the prescription was handled.

10. Always provide thorough patient counseling.
Approximately 83% of errors are discovered during counseling and are corrected before the patient leaves the pharmacy. Therefore, it is important to go beyond offering to counsel and provide counseling for each patient. It is considered good practice to open the container and show the actual medication to the patient during counseling rather than deliver it to the patient in a sealed bag. Completing this process will provide an opportunity for the patient to see the medication and ask questions if it looks different from what he or she has been taking. Counseling should also include the instructions on how to take the medication and appropriate route of administration. Many dispensing errors are attributed to misunderstood directions for use. Educating patients about safe and effective use of their medication promotes patient involvement in their health care, which will likely reduce medication errors.

The goal of every pharmacist is to minimize dispensing errors. Patient counseling being the last point of contact between the patient, pharmacist, and medication in the dispensing process is by far the most important strategy that every pharmacist must adopt in order to minimize dispensing errors. In addition, reporting errors as they occur and when they occur will help in learning from the mistakes and ultimately prevent such errors in the future.

Bar-coded medication administration

Bar-coded medication administration (BCMA) systems require that the nurse who administers the medication at the bedside should scan the patient's identification bracelet and the unit dose of the medication being administered. The system alerts the nurse to any mismatch of patient identity or of the name, dose, or route of administration of the medication. BCMA reduces medication errors by ensuring the five ‘rights’ of medication administration: the right patient, drug, dose, route, and time. BCMA systems reportedly produce 54–87% reductions in errors during administration of medications . In a London teaching hospital, implementation of a ‘closed-loop’ system including CPOE and BCMA reduced prescribing and medication administration errors . BCMA is reviewed in more detail elsewhere in this special issue .

Electronic medication reconciliation

With growing recognition that many inpatient medication errors occur at care transition points, reconciliation of medication lists during admission, transfer and discharge is an important step in improving safety. CPOE systems are effective in reducing errors during prescribing; however, a CPOE system cannot detect an error if the physician does not remember to prescribe a medication that the patient was taking at home. There is preliminary evidence that electronic medication reconciliation systems are quite effective in reducing such unintended discrepancies .

Medication administration discrepancies are likely to persist even after implementing CPOE and bar-coded medication administration unless recommended interventions are made to address issues such as determining the true urgency of medication administration, avoiding overlapping duplicative medication orders, and developing a safe means for shifting dosing schedules.

The implementation of health information technology can result
in a reduction in ADEs and can impact the quality of patient care.
Systems integration and compliance are vital in achieving a safe
medication use process. Hospitals that have extensive computerized
technology and have greater automation tend to have better patient
outcomes, including fewer complications, reduced inpatient
mortality and lower hospital costs. Regulatory agencies and
payers are now using performance standards and financial
incentives to force practice changes . This may increase the
speed and likelihood of technology implementation. While many
providers may dismiss technology as being beyond their scope of
practice or responsibility, both practitioners and patients should be
prepared for these changes.