What are 3 factors that can increase the risk of errors in a pharmacy setting?
Drug-drug interactions. Incorrect drug dosage. Inappropriate duration of drug treatment. Drug-allergy interactions.
- High patient volume.
- Unpredictable surges in patient volume.
- Difficult patients.
- Patients arriving unprepared or unable to share important medication and health information.
- Overwhelmed staff.
- High rotating staff.
- Staffing shortage.
- Prescribing.
- Omission.
- Wrong time.
- Unauthorized drug.
- Improper dose.
- Wrong dose prescription/wrong dose preparation.
- Administration errors include the incorrect route of administration, giving the drug to the wrong patient, extra dose, or wrong rate.
Type of the difficulties encountered . | Number of difficulties = 165 (concerning a total of 145 prescriptions) . |
---|---|
Drug or medical device ceased to be marketed | 2 (3.7%) |
Insufficient quantity prescribed | 2 (3.7%) |
Drug prescribed twice | 1 (1.9%) |
Dispensing of incorrect medication due to substitutions
One of the most serious potential errors that can occur is the dispensing of incorrect medication.
Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.
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Good documentation is:
- Accurate.
- Factual.
- Complete.
- Timely (current)
- Organized.
- Compliant with healthcare laws and facility standards.
Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors. Contributing factors to patient and caregiver error include low health literacy, poor provider–patient communication, absence of health literacy, and universal precautions in the outpatient clinic.
The most common medication error in the United States is administering the wrong dose to the patient. In the United States, these errors account for 43 percent of all fatalities linked to medication errors.
In most of the prescriptions, abbreviated terms are used by the prescriber that leads to major errors during interpretation by the pharmacists. For example: 'SSKI' is the abbreviated term of 'Saturated Solution of Potassium Iodide'. It is preferable to avoid these types of misleading abbreviations.
What is the biggest challenge pharmacists face?
1. Too many disparate resources. It is challenging to find a centralized, trustworthy evidence-based resource for drug information and drug interactions. Instead, pharmacists often have to sift through various books, tools, and other resources to find the drug data they need.
- Extended schooling. In addition to at least two years of undergraduate study, you must earn a Doctor of Pharmacy degree. ...
- Competitive field. ...
- Limited career advancement. ...
- Physical fatigue. ...
- Underappreciated work. ...
- High-pressure work.
- Staffing Shortages. ...
- Work Related Burnout & Stress. ...
- Slow Financial Recovery. ...
- Drug Pricing and Shortages. ...
- Technology & Automation. ...
- Cybersecurity. ...
- Telehealth. ...
- New Regulations for 2023.
Some factors leading to dispensing errors include high workload of pharmacists, brands/drugs with phonetic similarity, interruptions and distractions in the dispensing process, and an inability to understand doctor's handwriting [5].
Patients suffering from chronic diseases are at an increased risk of medication errors.
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.
- The Eight Common Root Causes of Medical Errors. ...
- Communication Problems. ...
- Inadequate Information Flow. ...
- Human Problems. ...
- Patient-Related Issues. ...
- Organizational Transfer of Knowledge. ...
- Staffing Patterns and Workflow.
- Technical Failures.
- Lack of awareness of expiration dates. Related Content. ...
- Taking the incorrect dosage. Recent Articles. ...
- Rate of usage. Advertisem*nt. ...
- What time of day to take the drug. ...
- Combining drugs without physician guidance.
- Know the various risks and causes for medication errors. ...
- Find out what drug you're taking and what it is for. ...
- Find out how to take the drug and make sure you understand the directions. ...
- Check the container's label every time you take a drug. ...
- Keep drugs stored in their original containers.
A pharmaceutical error can happen at any point in the prescription process from the time the medication is picked to the time the medication is dispensed. Most often, the error is by a nurse or doctor, but at times a pharmacist makes a mistake in filling or dispensing the prescription.
What are the common causes of risk when prescribing?
- MEDICINE REVIEW. Here failures arise primarily as a result of the prescriber or practice team not fully utilising the patient record system effectively. ...
- PRESCRIPTION ERROR. ...
- RECONCILIATION OF MEDICINES. ...
- KNOWN ALLERGY. ...
- CONTRAINDICATIONS.
The two main types of error in general practice are diagnostic and prescribing errors. The authors consider how they might arise and suggest ways in which they may be avoided.
- Fatigue: Fatigue is a prime factor that causes caregivers to become error-prone. ...
- Emotional stress: Emotional stress is another factor that can precipitate human error. ...
- Multitasking: Another activity that increases the likelihood of errors is multitasking.
One pharmacist acknowledged making 10 to 12 errors a year — “that are caught” — in an anonymous letter to the South Carolina Board of Pharmacy. While patients cannot control what happens behind the pharmacy counter, they can be on the lookout for errors. These simple steps can help.
Pharmacists are positioned to play a key role in preventing or catching errors that can occur at the various stages of the drug-use process: prescribing, dispensing, and administration.
High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Medical errors are also associated with extremes of age, new procedures, urgency, and the severity of the medical condition being treated.
Miscommunication of information in the clinical setting can result in medication errors. Medication errors were often a result of human factors including stress, fatigue, inexperience, lack of skills and lack of knowledge. Human factors influenced a lack of knowledge of the patient's medication history.
Risk Factors for Adverse Drug Events
Elderly patients, who take more medications and are more vulnerable to specific medication adverse effects than younger patients, are particularly vulnerable to ADEs.
Category | Description |
---|---|
A | No error, capacity to cause error |
B | Error that did not reach the patient |
C | Error that reached patient but unlikely to cause harm (omissions considered to reach patient) |
D | Error that reached the patient and could have necessitated monitoring and/or intervention to preclude harm |
Communication Problems
Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient.
What are common medication problems?
Adverse drug effects are effects that are unwanted, uncomfortable, or dangerous. Common examples are oversedation, confusion, hallucinations, falls, and bleeding. Among ambulatory people ≥ 65, adverse drug effects occur at a rate of about 50 events per 1000 person-years.
INVOLVE THE PATIENT
Look at the label, look at the name of the drug, look inside the bottle if it's a refill to make sure it's what you got last time.” Basic counseling can help ensure that patients understand what their prescription is for and how to take it properly; it sometimes helps catch errors as well.
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.
Category A – capacity to cause harm b. Category C – error reached patient; no harm c. Category E – error; temporary harm that required intervention d.
Action-based errors are those that are not intended (eg, misspelling or mistaken drug name). Memory-based errors involve forgotten information (eg, patient allergy).