Medication safety

This module provides a short introduction to the concept of medication safety: the theory behind medication errors, how often they occur, the reasons why they occur and what can be done to help prevent them.

Learning outcomes

By completing this module you will be able to:

• explain why medication errors occur
• understand the significance of medication errors
• recognise your individual responsibility in ensuring medication safety
• describe how and where to report medication incidents
• state the importance of the reporting process
• identify the importance of reflecting on medication incidents and/or near-miss events in your workplace.
  

Content Outline

1. Introduction
   1.1. How to use this module
   1.2. Learning outcomes
2. Medication safety - why does it matter?
   2.1. Medication errors - how big is the problem?
   2.2. Consequences of the medicatiion errors
3. Why do medication errors occur?
   3.1. Medication use in hospitals
   3.2. The Medication Use Pathway
4. Responsibility for medication safety
   4.1. Who is responsible
5. Why people make errors
   5.1. Not just human error
   5.2. Contributing factors
   5.3. Your practice
6. Learning from errors
   6.1. Open disclosure
   6.2. Reporting errors
7. Conclusion

This module is about common types of medication errors and the main causes of errors. It looks at how to help prevent them from occurring in the workplace

Learning outcomes

By completing this module you will be able to:

• identify the most common types and causes of medication errors that occur in the acute care setting
• describe why medication errors occur
• understand ways in which you can help prevent medication errors from occurring in your workplace.

Content Outline

1. Introduction
   1.1. How to use this module
   1.2. Learning outcomes
2. Types of medication errors
   2.1. Consequences of common types of errors
   2.2. Causes of medicaiton errors
   2.3. Working together to prevent errors
3. Omissions
   3.1. About omissions
   3.2. Common causes of omissions
4. Wrong dose
   4.1. Factors to consider
   4.2. The changing patient
   4.3. Dose calculation
   4.4. Route of administration
   4.5. Poor prescribing as a cause of dose errors
5. Wrong patient
   5.1. Prescribing for the right patient
   5.2. Referring to patients verbally
   5.3. Administering to the right patient
   5.4. Verifying patient identity
6. Wrong time
   6.1. Preventing timing errors
   6.2. Variable dose section of NIMC
   6.3. Factors to consider
7. Wrong drug
   7.1. Selecting the wrong drug
8. Wrong route
   8.1. Selecting the wrong route
9. Conclusion
   

This module looks at the many factors that can contribute to the wrong drug being prescribed, dispensed or administered to a patient.

Learning outcomes

By completing this module you will be able to:

• identify the factors that can contribute to the wrong drug being prescribed, dispensed or administered to a patient
• understand ways in which you can help prevent wrong drug errors from occurring in your workplace
• recognise the importance of reflecting on medication incidents and/or near-miss events.

Content Outline

1. Welcome
   1.1. How to use this module
   1.2. Learning outcomes
2. Causes of wrong drug errors
   2.1. Drug name confusion
3. Look-alike drug names
   3.1. Look-alike drug names errors
   3.2. Preventing look-alike errors
   3.3. Tall Man Lettering
4. Sound-alike drugs
   4.1. Causes of sound-alike drug errors
   4.2. Sound-alike errors when communicating with patients
   4.3. Preventing sound-alike drug errors
5. Product selection errors
   5.1. Similar packaging and labelling
   5.2. Similar packaging but different products
   5.3. Errors outside the pharmacy
   5.4. Avoiding product selection errors
   5.5. Barcode scanning to avoid product selection errors
6. Conclusion
   

This module explores the various types of wrong route errors and the many factors that can contribute to medications being administered to a patient by the incorrect route.

Learning outcomes

By completing this module you will be able to:

• explain the reasons why wrong route errors can occur
• understand ways in which you can help prevent wrong route errors from occurring in your workplace
• identify local, state and national policies, procedures and guidelines which contribute to the safe use of medicines
• recognise the importance of reflecting on medication incidents and/or near-miss events.

Content Outline

1. Introduction
   1.1. How to use this module
   1.2. Learning outcomes
2. Routes of administration
   2.1. One drug, many routes
   2.2. Consequences of wrong route errors
   2.3. Example
   2.4. Contributing factors
3. Labelling
   3.1. National Labelling Recommendations - line labelling
   3.2. National Labelling Recommendations - container labeling
4. Oral medications given intravenously
   4.1. Why are oral medications not suitable for intravenous use?
   4.2. Example one
   4.3. Example two
   4.4. Oral dispensers
   4.5. Intravenous medications given orally
   4.6. Intravenous medications given orally: Some precautions
5. Intravenous medications given intrathecally
   5.1. Example one
   5.2. Example two
   5.3. Intrathecal medication given intravenously
6. Intramuscular and intravenous mix-ups
   6.1. Intramuscular medications given intravenously
   6.2. Intravenous medication given intramuscularly
7. Intravenous and epidural mix-ups
   7.1. Preventing intravenous and epidural mix-ups
8. Intravenous medications given intra-arterially
9. Errors with ear and eye preparations
   9.1. Product selection errors
   9.2. Avoiding errors with eye and ear preparations
10. Other wrong route errors
11. Conclusion
    

In this module you will learn about the types of errors that can occur when using the intravenous (IV) route for drug administration. IV errors can occur at any point in the medication use pathway. We will explore the reasons why IV errors occur and suggest ways in which doctors, nurses and pharmacists can help to prevent these types of errors.

Learning outcomes

By completing this module you will be able to:

• explain why errors occur when using the intravenous (IV) route for administration of medications
• identify factors that contribute to IV drug errors
• understand ways in which you can help prevent IV drug errors from occurring in your workplace
• become familiar with local, state and national policies, procedures and guidelines that contribute to the safe use of IV medicines
• recognise the importance of reflecting on IV medication incidents and/or near-miss events.

Content Outline

1. Introduction
   1.1. How to use this module
   1.2. Learning outcomes
2. Why do we use the IV route?
   2.1. Why do errors occur with the IV route?
   2.2. How big is the problem?
3. Intravenous dose errors
   3.1. Dose calculations
   3.2. Presentation of IV products
   3.3. More problems with IV products
   3.4. Calculation of volume
   3.5. IV dose vs. oral dose
   3.6. Communication errors
4. Rate errors
   4.1. Choosing the right administration method
   4.2. Choosing the right device to control the rate
5. Concentration errors
6. Compatibility errors
   6.1. Checking for compatibility
7. Reconstitution errors
   7.1. Displacement values
   7.2. Other considerations
8. Mixing errors
9. Wrong drug errors
   9.1. Product selection errors
10. Labelling
    10.1. ACQSHC National Labelling Recommendations
    10.2. Labelling Recommendations: Container identification
    10.3. Labelling Recommendations: Burette identification
    10.4. Labelling Recommendations: Line identification
    10.5. Labelling Recommendations: Standardised labels
11. Wrong patient errors
12. Reducing the risk of intravenous error
13. Conclusion

This module explores the various types of errors that can occur when dealing with different formulations of medications. It explores ways to prevent these types of errors from occurring in the workplace.

Learning outcomes

By completing this module you will be able to:

• recognise the patient safety issues associated with selecting the wrong formulation of a medication
• understand the reasons why formulation errors occur
• identify ways in which you can help to prevent formulation errors from occurring in your workplace
• identify the importance of reflecting on medication incidents and/or near-miss events.
  

Content Outline

1. Introduction
   1.1. How to use this module
   1.2. Learning outcomes
2. Why so many formulations?
3. Controlled-release formulations
   3.1. What is a controlled-release formulation?
   3.2. Differences in dosing schedules
   3.3. What happens if the wrong formulation is administered?
   3.4. Determining the correct formulation
   3.5. Appropriate use of controlled-release products
   3.6. Causes of errors with controlled-release formulations
   3.7. Morphine formulations
   3.8. Oxycodone formulations
   3.9. Non oral medications available in controlled-release formulations
   3.10. Preventing errors with controlled-release formulations
   3.11. Preventing errors with controlled-release formulations - the NIMC
4. Crushing and chewing medications
   4.1. Formulations that should not be crushed
   4.2. Can controlled-release tablets be halved?
   4.3. Opening capsule formulations
   4.4. Example: crushing and chewing medications
5. Combination products
   5.1. Pros and cons of combination products
   5.2. Prescribing of combination products
   5.3. Checking the strength of combination products
   5.4. Availability of combination products in hospitals
6. Oral liquids
   6.1. Safe use of oral liquids
7. Drug delivery devices
   7.1. Transdermal patches
   7.2. Disposal of transdermal patches
   7.3. Safe use of opioid patches
8. Conclusion
   

This module explores how good, structured communication processes can help improve the safety of medication use in hospitals.

Learning outcomes

By completing this module you will be able to:

• identify ways in which you can improve your communication skills and approaches that can help to prevent errors from occurring in your workplace
• understand how unclear, ineffective or inadequate communication can result in medication errors
• recognise the importance of reflecting on medication incidents and/or near-miss events.

Content Outline

1. Introduction
   1.1. How to use this module
   1.2. Learning outcomes
2. The need for effective communication
3. Written communication
   3.1. Forms of written communication
   3.2. Example of miscommunication
   3.3. Tips for clearer documentation
4. Safe prescribing
   4.1. Use of abbreviations
   4.2. Safe use of decimal points
   4.3. Decimal point errors
   4.4. Guidelines for use of terminology, abbreviations and symbols in prescribing
   4.5. The importance of clear prescribing
5. Verbal ordering
   5.1. Verbal ording errors - contributing factors 5.2. Verbal ordering - scenario 1
   5.3. Verbal ordering - scenario 2
   5.4. Tips for ensuring verbal orders are used safely
   5.5. Verification of verbal orders
6. Working together
   6.1. Interdisciplinary communication
   6.2. Engaging the listener - how you say it
   6.3. Engaging the listener - what you say
   6.4. Engaging the listener - scenario 1
   6.5. Engaging the listener - scenario 2
   6.6. Structured communication tools
7. The authority gradient
   7.1. The perception of an authority gradient
   7.2. Methods for communicating up the authority gradient
   7.2. The Graded Assertiveness technique
   7.3. PACE Step by Step
   7.4. PACE Scenario
   7.5. Developing your communication skills
8. An Australian case
9. Conclusion
   

This case study explores the case of Mr F, a 48-year-old man who presented to the emergency department yesterday.

Learning outcomes

By the end of this case study the learner will be able to:

• apply principles of medication safety to a clinical scenario
• identify factors contributing to a medication incident or near miss.

Key learning points (and related modules) from this case study.

• Acting on medication errors and near misses (module 1)
  • importance of acknowledging and reporting errors
• Wrong dose errors (module 2)
  • importance of individualising doses and following evidence-based guidelines
• Wrong time errors (module 2)
  • importance of ensuring that the frequency and administration times match up
• Omission errors (module 2)
  • importance of VTE risk assessment for all patients
  • what to do if a prescribed product is not available
• Wrong drug errors (module 3)
  • being vigilant to look-a drug names
  • importance of prescribing by generic name
• Wrong route errors (module 4)
  • never giving oral products via the IV route
• Intravenous rate errors (module 5)
  • importance of clear prescribing of IV medications and fluids
  • importance of using other routes as soon as possible
  • importance of considering a medication's bioavailability when switching from IV to other routes of administration.
• Written communication (module 6)
  • use of error prone abbreviations and symbols
  • importance of clear and legible handwriting.

This case study you explores how a simple omission error resulted in a serious outcome for the patient. Errors like this can have other consequences, such as a loss of trust in the healthcare system by the patient and his family, a loss of confidence and feelings of guilt by the healthcare professionals concerned and potential medico-legal implications.

Learning outcomes

By the end of this case study the learner will be able to:

• apply principles of medication safety to a clinical scenario
• identify factors contributing to a medication incident or near miss.

Key learning points (and related modules) from this case study.

• Acting on medication errors and near misses (module 1)
  • importance of acknowledging and reporting errorhe process of open disclosure
• Omission errors (module 2)
  • the need to ensure the best possible medication history is obtained from the patient
  • the need to assess the patient's medical history to help identify any omissions of standard therapy
  • the importance of attention to detail when transcribing medication orders.