HomeHealth A-ZApproach to Reduce Repeated Medication Error (REREME) in a Multispecialty Tertiary Care...

Approach to Reduce Repeated Medication Error (REREME) in a Multispecialty Tertiary Care Hospital in Eastern India

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Mr. Akash Karmakar

Assistant Manager, Quality Cell;

Apollo Multispeciality Hospital, Kolkata

Dr. Mrinal Das

General Manager, Clinical Pharmacology;

Apollo Hospital Enterprise Limited

Abstract:

Background:

Medicines become one of the amongst the foremost important of health care systems worldwide. Medicine saves our lives. Medicines are the common intervention, use to treat diseases however Medicines themselves can result in Medication Error which at times may be harmful to the patient if proper intervention are not practiced, because the language justly goes “Medicines are two-edged sword”. Therefore monitoring of the Medication process is very important in prevention of Medication Error by implementing appropriate strategies to reduce patient harm. Continuously monitoring of all Medication Error and also the repeated Medication Error as they might pass through the preventive mechanism and just like The Swiss cheese1 phenomenon the repeated Medication Error may have the tendency to pass through the system if not addressed and may lead to reaching to the patient and may cause patient harm. Monitoring along with root cause, its analysis and reporting to Hospital Management, Quality and respective stockholders can lead to formulation of strategy which can prevent such repeated Medication Error to reach the patient and do harm.

Methodology:

The study conducted by collection of Medication Error data on prescription, transcription, dispensing, administration on online incident reporting system and also hard copy of data collection form. Data processing and statistically analyzed based on MS Xcel Platform. Based on the analysis strategic planning done to reduce the repeated Medication error with the help of Drug & Therapeutic committee, doctors opinion, Nursing, quality department, pharmacy department.

Results:

After analysis of the data it is observed that a significant number of error are there in Prescription and Transcription and after taking specific action to reduce them, in the next few months it is reduced to a great extent. Not only that the subcategory of the errors are also Conclusion:

Our study observed that by taking specific action towards reduction of Medication error which are repeated in type a significant number of the reduction can be achieved which gives patient safety.

Keywords:                                                                                                          Medication Error, Prescription Error, Transcription Error, Dispensing Error, Administration Error.

Introduction:

Medicines become one of the amongst the foremost important of health care systems worldwide. Medicine saves our lives. Medicines are the common intervention, use to treat the diseases however Medicines themselves can result in Medication Error which at times may be harmful to the patient if proper intervention are not practiced, because the language justly goes “Medicines are two edged sword”.

NCC MERP Defines Medication Error2 as “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer”. Therefore monitoring of the Medication process is very important in prevention of Medication Error by implementing appropriate strategies to reduce patient harm. Continuously monitoring of all Medication Error and also the repeated Medication Error as they might pass through the preventive mechanism and just like The Swiss cheese1 phenomenon the repeated Medication Error may have the tendency to pass through the system if not addressed and may lead to reaching to the patient and may cause patient harm. Monitoring along with root cause, its analysis and reporting to Hospital Management, Quality and respective stockholders can lead to formulation of strategy which can prevent such repeated Medication Error to reach the patient and do harm.

Monitor the patients prescription, than transcription of the prescription in online module and after that dispensing and finally the administration of medication is done to observe, detect any Medication Error in the system. Our primary goal is to ensure complete medication system observation, identification of Medication Error with evidence and raise it as an incident into the system and accordingly analyzed it to understand the repeated medication errors, so that preventive strategies can be formulated and put into practice to minimize the repeated medication error or medication error per se.

The main objective of the observation of Medication Error is to identify the repeated Medication Errors in the systems and to minimize it with application of good practices as per standards3.

This study helps to motivate to health care professional (Doctors, Pharmacist, and Nurses) to understand the gap that is there in terms of Medication Error, specifically the repeated Medication Error and thereby safeguarding the patient in terms of harm if occurred.

Aim of the project – To monitor all medication errors and repeated medication errors with root cause analysis4 and its preventive steps to ensure patient safety while treatment is being provided in our hospitals.

Methodology:

Project design – Hospital based prospective observational study. Data Collection Method online incident report based using AIRS (Apollo Incident Reporting System) and hard copy of the data collection form.

Project subject/ Materials

  • Patient hospitalized with complain of Medical/Surgical ailments.
  • Demographic details- Age, Gender, Weight, allergic history (patient name will confidential)
  • Primary complain for hospitalization is being note.
  • Drug data – Drug (Brands Name, Generic name), Dose, Documentation of Drug dose, route & frequency, Route of administration and frequency of dosing will be record.
  • Medication Errors – Prescription Error, Transcription Error, Dispensing Error5 & Administration Error.

Inclusion criteria

  • Medication Error pertaining to prescription Error, Transcription Error, Dispensing Error & Administration Error as per the standard Definition happened in the Hospital premises.

Exclusion criteria –

  • Medication Error outside of the Hospital premises.
  • Medication error related Homeopathy, Ayurvedic preparation and Unani medicine.
  • Any information deemed not fit as per the definition.

Study Period April’22 to Sep’22

Strategy:

All Medication Charts, Transcription into computer module ,dispensing module and Drug administration details in medication charts are  being audited by clinical pharmacists, as per below discussed path way –

  • Prescription is audited in the Medication Chart thereby detecting Prescription Error.
  • Transcription is being monitored in the transcription module in the computer system by clinical pharmacists and thereby detecting transcription error.
  • Dispensing is monitored while dispensing by checking pharmacists,
  • Clinical pharmacists while dispensing.
  • Drug administration Error is detected by checking the drug administration details in the medication chart by clinical pharmacists.
  • Analysis of the error on regular monthly basis and understanding the repeated medication error by clinical pharmacologists and Quality Team of the hospital.
  • Repeated Medication Error trend identification and preventive strategies6

Plan of work –

  • Who can report Medication Error – Medical Team, Nurses and Pharmacist into the AIRS( Apollo Incident Reporting system)
  • Responsibility – Clinical Pharmacists
  • Audit schedule – Regular
Planning /strategies for reduction of repeated Medication Error.  
Error Monitoring by clinical Pharmacists for Medication

Ethical Considerations:

  • Statistical Analysis – The data collected through online AIRS portal of incident reporting are converted into MS excel sheet and analyzed on various aspects of Medication Errors2 and also the hard copy of the data is tallied for data validation. Proportional chi-square test was used to determine whether or not the errors had decreased significantly. 
  • Results-

As per analysis since April ’22 to June’22.

 Figure no. 1 – In terms of months (April 2022 – June 2022) categories of medication errors

Figure no. 2 – In terms of months (April 2022 – June 2022) error type wise analysis of transcription errors

Figure no. 3 – In terms of months (April 2022 – June 2022) type of drug wise analysis of transcription errors

Figure no. 4 – In terms of months (April 2022 – June 2022) drug category wise analysis of transcription errors

  Figure no. 5 – In terms of months (April 2022 – June 2022) Top five types Causes of Transcription errors

Figure no. 6 – In terms of months (April 2022 – June 2022) error type wise analysis of prescription errors

Figure no. 7 – In terms of months (April 2022 – June 2022) type of drug wise analysis of prescription errors

Figure no. 8 – In terms of months (April 2022 – June 2022) drug category wise analysis of prescription errors

Figure no. 9 – In terms of months (April 2022 – June 2022) Top five types Causes of Prescription errors

Figure no. 10 – In terms of months (April 2022 – June 2022) Top five types Causes of Administration errors

Figure no. 11 – In terms of months (April 2022 – June 2022) drug category wise analysis of Administration errors

Figure no. 12 – In terms of months (April 2022 – June 2022) drug category wise analysis of Dispensing errors

Figure no. 13 – In terms of 7 rights (April 2022 – June 2022) analysis of Administration errors

Figure no. 14 – In terms of percentage (April 2022 – June 2022) type of medication errors

Summary of the Medication Error (April 2022 to June 2022):-

The Medication Error were analyzed and it was observed that there are significant number of Error in terms of Prescription error of 49 (22+16+11) out of which there were 46 Medication Error near miss and 3 Medication Error reached to patient without harm, Transcription Error of 72 (32+19+21) out of which there were all near misses, Administration Error of 10(4+2+4) and all reached the patient without harm and Dispensing Error of 2 and all are near miss.

As per the intent of the project we choose the Medication Error which are more and repeated in nature to focus or analyze upon and we selected Prescription Error, Transcription Error and Administration Error. On further analysis of the data we found the break up as below-

Prescription Error– as per repetition

Location wise it is observed that the Hospitals second floor with 13 errors, Third floor with 11 errors, fourth floor with 8 errors , first floor with 7 errors and oncology wit 4 number of errors.

Elements of the prescription wise observed that Dose is 18 occasion, Unit is 9 occasions, Route is 8 occasions, Frequency is 5 occasions are repeated

Drug Category wise analysis is it observe that Controlled/narcotic drugs 13 occasions, GIT 4 occasions, Electrolyte and Antibiotic in 3 occasions are repeated in nature.

Transcription Error: – as per repetition

Location wise it is observed that the Hospitals second floor with 19 errors, Third floor with 11 errors, fourth floor with 8 errors , first floor with 10 errors and oncology with 15 number of errors.

Elements of the transcription wise observed that Dose is 11 occasion, Unit is 6 occasions, Route is 8 occasions, Frequency is 22 occasions and name of the drug on 10occasions are repeated

Drug Category wise analysis is it observe that Chemotherapy drugs 5 occasions, GIT 7 occasions, Antibiotic in 10 occasions , Antidepressant 7 occasions and multivitamins are 4 occasions are repeated in nature.

Administration Error: – as per repetition

Location wise it is observed that the Hospitals Third & First floor having more number of errors.

Elements of the administration wise observed that Documentation of drug administration error in 3 occasions are repeated

Drug Category wise analysis is it observe that Antibiotic on 4 occasions and GIT on 3 Occasions are repeated in nature.

Dispensing Error: – as per repetition we could not found any trend as there are very few dispensing error.

Interventions:

Focused activities like Medication Safety week/months, Implementation of 7 rights of Drug Administration7. Pharmacy triple checking of the dispensing with clinical Pharmacy intervention, AIRS incident reporting with closing of the loop by HODs with discussion with the staff. Regular counseling, unit based class, on the job class, class room training, focused Drug administration class to nursing etc.

The following interventions were done starting from July 2022:

  • Continuous monitoring of error by prescription Audit & Clinical Pharmacology Dept.
  • Analysis of the errors regular basis to understand variations from standard and focus on the observations.
  • Regular round in wards and related areas to check whether standard guidelines are followed or not.
  • Classes for staff on specific errors and standard policies shall be continued.
  • Feedback from staffs on any Medication process issues and further resolving of those issues done regularly
  • Regular discussion with IT dept. if any observations noticed
  • Regular analysis of errors to see any variations from the standard and focused action done as needed
  • Regular medication round to check practice of the standard. Any observation were addressed immediately
  • Regular interaction with staffs to check understanding and implementation of the guidelines in practice and on spot explanation and education continued
  • IT person in pharmacy advised by pharmacy management to have regular interaction of any issues.

Results:

The Medication Error were analyzed and it was observed that there are significant reduction in the number of Error in terms of Prescription error of 27( 10+8 +9) out of which there were 19 Medication Error near miss  and 8 Medication Error reached to patient without harm, Transcription Error of 39 ( 17+11+11) out of which there were all near misses 37 and 2 Medication Error reached the patient without any harm, Administration Error of 7(1+1+5) and all reached the patient without harm and Dispensing Error of 8 (1+4+3) and all are near miss.

As per the intent of the project we choose the Medication Error which are more and repeated in nature to focus or analyze upon and we selected Prescription Error, Transcription Error and Administration Error. On further analysis of the data we found the break up as below-

Prescription Error: as per repetition

Location wise it is observed that the Hospitals second floor with 10 errors, Third floor with 3errors, fourth floor with 5 errors , first floor with 4 errors and oncology with 4 number of errors.

Elements of the prescription wise observed that Dose is 7 occasion, Unit is 0 occasion, Route is 7occassions, Frequency is 3 occasions are repeated

Drug Category wise analysis is it observe that Controlled/narcotic drugs 9 occasions, GIT 2 occasions, Electrolyte 1 occasions and Antibiotic in 0 occasions are repeated in nature.

Transcription Error: as per repetition

Location wise it is observed that the Hospitals second floor with 11 errors, Third floor with 4 errors, fourth floor with 8 errors , first floor with 6errors and oncology with 2 number of errors.

Elements of the transcription wise observed that Dose is 3 occasion, Unit is 1 occasions, Route is 1 occasions, Frequency is 11 occasions and name of the drug on 12 occasions are repeated

Drug Category wise analysis is it observe that Chemotherapy drugs 0 occasions, GIT 5 occasions, Antibiotic in 4 occasions , Antidepressant 3occasions and multivitamins are 0 occasions are repeated in nature.

Administration Error: as per repetition

Location wise it is observed that the Hospitals Third & First floor having Zero number of errors.

Elements of the administration wise observed that Documentation of drug administration error in 1 occasions are repeated

Drug Category wise analysis is it observe that Antibiotic on 1 occasions and GIT on 0 occasion are repeated in nature.

Dispensing   Error: as per repetition we could not found any trend as there are very few dispensing error.

From the above data it was clear that there is significant number of reduction of the repeated Medication Error in the next three months which were prominent in the previous three months. And there is also no harm to patient.

Figure 15: In terms of months (July – September 2022) categories of medication errors

Figure no. 16 – In terms of months (July – September 2022) error type wise analysis of prescription errors

Figure no. 17 – In terms of months (July – September 2022) type of drug wise analysis of prescription errors

Figure no. 18 – In terms of months (July – September 2022) Top five types Causes of Prescription errors

Figure no. 19 – In terms of months (July – September 2022) drug category wise analysis of prescription errors

Figure no. 20 – In terms of months (July – September 2022) type of drug wise analysis of Transcription errors

Figure no. 21 – In terms of months (July – September 2022) drug category wise analysis of Transcription errors

Figure no. 22 – In terms of months (July – September 2022) drug category wise analysis of Administration Errors

Figure no. 23 – In terms of 7 rights (July – September 2022) analysis of Administration errors

Figure no. 24 – In terms of months (July – September 2022) error type wise analysis of Dispensing errors

Figure no. 24 – In terms of months (July – September 2022) type of drug wise analysis of Dispensing errors

Figure no. 25 – In terms of percentage (July – September 2022) type of medication errors

Limitations of the Study:

The study has some limitations. As the Medication Error were observed and detected ,there may be some errors are undetected once it is not withitn the observatinal process.

Conclusion:

From the above monitoring, discussion, analysis and action taken it was clear that there is a significant number of reduction in Medication Error and that is also applicable to the repeated medication error which were focused on the various action taken activities.

Medication Error per se were also reduced due to action taken activity which was devised after thorough analysis and planned action to reduce it for the sack of patient safety. Focusing on the more number of Medication Errors in Prescription & Transcription Error category, there are total 49 (22+16+11) prescription error in the span of last three months were reduced to 27( 10+8+9) and the Transcription Error 72(32+19+21) were reduced to 39(17+11+11). Administration Error were also reduced to 7 from previous 10.

Repeated Medication error which were significant the previous three months are also reduced in the next three months as focused action taken activities were implemented and continued.

Comparison of Repeated Medication Error –

Prescription ErrorApril – June 2022July – September 2022
LocationsFirst Floor74
Second Floor1310
Third Floor113
Fourth Floor85
Oncology44
MedicationControlled Drugs139
GIT Drug42
Electrolyte31
Antibiotic30
Elements of PrescriptionDose187
Unit90
Route87
Frequency53

All Error were reduced since previous three months.

Transcription  Error April – June 2022July – September 2022
LocationsFirst Floor106
Second Floor911
Third Floor114
Fourth Floor88
Oncology152
MedicationAnti-Depressant73
GIT Drug75
Chemotherapy Drugs50
Antibiotic104
Vitamins40
Elements of TranscriptionDose113
Unit61
Route81
Frequency2111
Name of Drug1012

All Error were reduced since previous three months except the subcategory of errors in transcription in name of the drug where we observed two number were increased from previous months although overall error reduced. Similarly in locations the fourth floor error number remains the same hovering around at 8 although overall error were reduced. Therefore sustained activity of action were continued in those areas apart from routine monitoring, detection, action taken etc.

Since Administration Error & Dispensing Error were not so significantly repeated those were continued on monitoring and sustained on action taken activities.

This way on analyzing the Medication Error and further analyzing the repeated Medication Error after which focused action taken on the weak points based on strategic action plan in the form of Medication Action taken form implementation, daily morning Medication huddle, daily discussion with Head of the department on Medication Error in operations morning huddle, weekly discussion on the Ward as a unit meeting, quarterly discussion and analysis in Drug & Therapeutic committee meeting and also focused activities like Medication Safety week/months, Implementation of 7 rights of Drug Administration. Pharmacy triple checking of the dispensing with clinical pharmacy intervention, AIRS incident reporting with closing of the loop by HODs with discussion with the staff. Regular counseling, unit based class, on the job class, class room training, focused Drug administration class to nursing etc. can lead to reduction of the repeated medication error and it is a sustainable project and practice which can be adopted by other institution and organization for the sack of patient safety.

The study data were put into statistical test analysis applying the chi square test for evaluating the p value for it significance and in terms of prescription error reduction in repeated error it was found that there is significant value for reduction in the error as locations wise reduction P is 0.041 and elements of prescription error reduction P is 0,.002 and in both the occasions were significant and thereby suggesting that the study has a significant impact in reducing the repeated medication error in prescription.

Prescription Error – Locations

Total43260.041Significant

Elements of Prescription

Total40170.002Significant

In terms of Transcription error reduction in repeated error it was found that there is Significant value for reduction in the error as locations wise reduction P is 0.0016 and I terms of repeated reduction in Medication P is 0.002 and in the elements of transcription error reduction P is 0.002 and in all the occasions were significant and thereby suggesting that the study has a significant impact in reducing the repeated medication error in Transcription.

Transcription Error – Locations 

Total53310.016Significant


Transcription Error – Medication

Total33120.002Significant


Elements of Transcription

Total56280.002Significant

Therefore overall it was seen that the significance value of P is significantly within limit for making the study statistically relevant in reducing the repeated medication error which were focused on for reduction with appropriate strategies.

 April – June 2022 July – September 2022 p valueSignificance
Prescription Error  10655< 0.0001Significant
Transcription  Error  14271< 0.0001Significant

Using chi-square proportion test, we discovered that overall prescription errors and transcription errors were significantly reduced in Q2 (July-September 2022) compared to Q1 (April-June 2022), with p values of <0.0001 in both cases. 

Acknowledgement:

We would like to acknowledge the support and help from the Hospital authority for conducting the study and also members from Quality, Medical, Nursing, pharmacy department.

Conflict of Interest:

There is no conflict of Interest

Funding:

Nil

Authors Contribution:

Author MD involved in the concept of the study and AK involved in the manuscript design. MD and AK both involved in the literature search, writing, editing, and drafting of the manuscript.

References:

1. The Swiss cheese model of safety incidents: are there holes in https://www.ncbi.nlm.nih.gov › articles › PMC1298298.

2. About Medication Errors | NCC MERP – https://www.nccmerp.org › about-medication-errors

3. JCI Accreditation Standards for Hospitals, 7th Edition – https:// store.jointcommissioninternational.org › jci-accre.

4. Root Cause Analysis and Medical Error Prevention Gunjan Singh; Raj H. Patel; Joshua Boster.

Author Information Gunjan Singh1; Raj H. Patel2; Joshua Boster3.

1 Membership of the Royal College of Obstetricians and Gynecologists

2 University of South Florida

3 Uniformed Services University of the Health Sciences,Last Update: August 7, 2022.

5. Medication Dispensing Errors And Prevention

Rayhan A. Tariq; Rishik Vashisht; Ankur Sinha; Yevgeniya Scherbak.

Author Information Rayhan A. Tariq1; Rishik Vashisht; Ankur Sinha2; Yevgeniya Scherbak.

1 Drexel University College of Medicine

2 Parkview Regional Medical Center, Last Update: July 3, 2022.

6. Medication errors: what they are, how they happen, and how to avoid them 

J.K. Aronson QJM: An International Journal of Medicine, Volume 102, Issue 8, August 2009, Pages 513–521, https://doi.org/10.1093/qjmed/hcp052 Published: 20 May 2009

7. What Are the 7 Rights of Medication?

Written by Victoria Hamilton, Medically Reviewed by Jabeen Begum, MD on October 10, 2022

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