topic 11: improving medication safety - world health organization

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Topic 11: Improving medication safety

Why focus on medications? Medicines have proven to be verybeneficial for treating illness and preventingdisease. This success has resulted in a dramaticincrease in medication use in recent times.Unfortunately, this increase in use and expansionof the pharmaceutical industry has also broughtwith it an increase in hazards, error and adverseevents associated with medication use.

Medication has also become increasinglycomplex: • There has been a massive increase in the

number and variety of medications available.These may have different routes of delivery,variable actions (long acting, short acting) andthere are drugs with the same action andformulation but with different trade names.

• Although there are better treatments forchronic disease, more patients take multiplemedications and there are more patients withmultiple co-morbidities. This increases thelikelihood of drug interactions, side-effectsand mistakes in administration.

• The process of delivering medications topatients is often shared by a number ofhealth-care professionals. Communicationfailures can lead to gaps in the continuity ofthe process.

• Doctors are prescribing a larger range ofmedications so there are more medicinesthey need to be familiar with. There is just toomuch information for a doctor to be able toremember in a reliable way.

• Doctors look after patients who are takingmedications prescribed by other doctors(often specialized doctors) and hence maynot be familiar with the effects of all themedications a patient is taking.

Doctors have a major role in the use of medicine.Their role includes prescribing, administration,monitoring for side-effects, working in a team

and potentially a leadership role in the workplacein relation to medication use and improving patient care.

As future doctors, medical students need tounderstand the nature of medication error, learnwhat the hazards are in relation to usingmedication and what can be done to makemedication use safer. All staff involved in the useof medication have a responsibility to worktogether to minimize patient harm caused bymedication use.

KeywordsSide-effect, adverse reaction, error, adverse event,adverse drug event, medication error, prescribing,administration and monitoring.

Learning objectives: • to provide an overview of medication

safety;• to encourage students to continue to learn

and practise ways to improve the safety ofmedication use.

Learning outcomes: knowledge andperformance

What a student needs to know (knowledgerequirements): • understand the scale of medication

error;• understand that using medications has

associated risks;• understand common sources of error;• understand where in the process errors

can occur;• understand a doctors’ responsibilities when

prescribing and administering medication;• recognize common hazardous situations;• learn ways to make medication use safer;• understand the benefits of a multidisciplinary

approach to medication safety.

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What a student needs to do (performancerequirements) Acknowledge that medication safety is a vasttopic and an understanding of the area will affecthow a clinician performs in the following tasks:• use generic names;• tailor prescribing for each patient;• learn and practise thorough medication

history taking;• know the high-risk medications;• be very familiar with the medications you

prescribe;• use memory aids;• communicate clearly;• develop checking habits;• encourage patients to be actively involved in

the medication process;• report and learn from errors;• learn and practise drug calculations.

WHAT STUDENTS NEED TO KNOW(KNOWLEDGE REQUIREMENTS)

Definitions:

Side-effect A known effect, other than that primarily intended,relating to the pharmacological properties of themedication [1]. For example, a common sideeffect of opiate analgesia is nausea.

Adverse reactionUnexpected harm arising from a justified actionwhere the correct process was followed for thecontext in which the process occurred [1]. Forexample, an unexpected allergic reaction in apatient taking a medication for the first time.

ErrorFailure to carry out a planned action as intendedor application of an incorrect plan.[1]

Adverse event An incident that results in harm to a patient.[1]

Adverse drug event An incident that may be preventable (usually theresult of an error) or not preventable.

Medication errorMay result in:• an adverse event if a patient is harmed;• a near miss if a patient is nearly harmed;• neither harm nor potential for harm.

Understand the scale of medicationerror Medication error is a common cause ofpreventable patient harm.

The Institute of Medicine in the United Statesestimates:• 1 medication error per hospitalized patient

per day in the United States; [2]• 1.5 million preventable adverse drug events

per year in the United States; [2]• 7000 deaths per year from medication error in

US hospitals. [3]

Other countries around the world that haveresearched the incidence of medication error andadverse drug events have similarly worryingstatistics [4].

Steps in using medication There are a number of discrete steps in usingmedication: prescribing, administration andmonitoring are the main three. Doctors, patientsand other health professionals can all have a rolein these steps. For example, a patient may self-prescribe over-the-counter medication, administertheir own medication and monitor themself to seeif there has been any therapeutic effect.Alternatively, for example, in the hospital setting,

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one doctor may prescribe a medication, a nursewill administer the medication and a differentdoctor may end up monitoring the patient’sprogress and make decisions about the ongoingdrug regimen.

The main components of each step are outlinedbelow.

Prescribing:• choosing an appropriate medication for a

given clinical situation, taking individualpatient factors into account such as allergies;

• selecting an administration route, dose, timeand regimen;

• communicating the plan with whoever willadminister the medication. Thiscommunication may be written, verbal or both;

• documentation.

Administration:• obtaining the medication and having it in a

ready-to-use form. This may involve counting,calculating, mixing, labelling or preparing insome way;

• checking for allergies;• giving the right medication to the right patient,

in the right dose, via the right route, at theright time;

• documentation.

Monitoring:• observing the patient to determine if the

medication is working, being used correctlyand not harming the patient;

• documentation.

There is potential for error at every step of theprocess. There are a variety of ways that error canoccur at each step.

Understand that using medications hasassociated risks

Prescribing

Sources of error in prescribing:• Inadequate knowledge about drug

indications, contraindications and druginteractions. This has become an increasingproblem as the number of medicines in usehas increased. It is not possible for a doctorto remember all the relevant details necessaryfor safe prescribing. Alternative ways ofaccessing drug information are required.

• Not considering individual patient factors thatwould alter prescribing such as allergies,pregnancy, co-morbidities like renalimpairment and other medications the patientmay be taking.

• Prescribing for the wrong patient, prescribingthe wrong dose, prescribing the wrong drug,prescribing the wrong route or the wrongtime. These errors can sometimes occur dueto lack of knowledge, but more commonly area result of a “silly mistake” or “simplemistake”, referred to as a slip or a lapse.These are the sorts of errors that are morelikely to occur at 04:00, or if the doctor isrushing or bored and not concentrating onthe task at hand.

• Inadequate communication can result inprescribing errors. Communication that isambiguous can be misinterpreted. This maybe a result of illegible writing or simplemisunderstanding in verbal communication.

• Mathematical error when calculating dosescan cause errors. This can be a result ofcarelessness, but could also be due to lack oftraining and unfamiliarity with how tomanipulate volumes, amounts,concentrations and units. Calculation errorsinvolving medications with narrow therapeuticwindow can cause major adverse events. Not

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uncommonly, a calculation error can occurwhen transposing units (e.g. from microgramsto milligrams) and may result in a 1000 timeserror. Competence with dose calculations isparticularly important in paediatrics wheremost doses are determined according to theweight of the child.

Administration

Types of administration errors:• Classic administration errors are a drug being

given to the wrong patient, by the wrongroute, at the wrong time, in the wrong dose orthe wrong drug used. Not giving a prescribeddrug is another form of administration error.These errors can result from inadequatecommunication, slips or lapses, lack ofchecking procedures, lack of vigilance,calculation errors and suboptimal workplaceand medication packaging design. There isoften a combination of contributory factors.

• Inadequate documentation. For example, if amedication is administered but has not beenrecorded as being given, another staff membermay also give the patient the medicationthinking that it had not yet been administered.

Monitoring

Types of errors in monitoring:• inadequate monitoring for side-effects;• medication not ceased once course is

complete or clearly not helping the patient;• course of prescribed medication not

completed;• drug levels not measured, or measured but

not checked or acted upon;• communication failures—this is a risk if the

care provider changes, for example, if thepatient moves from the hospital setting to thecommunity setting or vice versa.

Contributory factors for medication errorsAdverse medication eventsare frequently multifactorial in nature. Often thereis a combination of events that together result inpatient harm. This is important to understand for anumber of reasons. In trying to understand whyan error occurred, it is important to look for all thecontributing factors, rather than the most obviousreason or the final point of the process. Strategiesto improve medication safety also need to betargeted at multiple points.

Patient factors:• patient on multiple medications;• patients with a number of medical problems;• patients who cannot communicate well, e.g.

unconscious, babies and young children,people who do not speak the same languageas the staff;

• patients who have more than one doctor`prescribing medication;

• patients who do not take an active interest inbeing informed about their own health andmedicines;

• children and babies (drug dose calculationsrequired).

Staff factors:• inexperience;• rushing, emergency situations;• multitasking;• being interrupted mid-task;• fatigue, boredom, lack of vigilance;• lack of checking and double-checking habits;• poor teamwork, poor communication

between colleagues;• reluctance to use memory aids.

Workplace design factors:• absence of safety culture in the workplace.

This may be evidenced by a lack of reportingsystems and failure to learn from past near

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misses and adverse events;• absence of readily available memory aids

for staff;• inadequate staff numbers;• medicines not stored in an easy to use form.

Medication design factors:• look-a-like, sound-a-like medication. For

example, Celebrex (an anti-inflammatory),Cerebryx (an anticonvulsant) and Celexa (anantidepressant);

• ambiguous labelling—different preparations ordosages of similar medication may havesimilar names or packaging. For example,some slow release medications maydifferentiate themselves from the usualrelease form with a suffix. Unfortunately, thereare many different suffixes in use to implysimilar properties such as slow release,delayed release or long acting, e.g. LA, XL,XR, CC, CD, ER, SA, CR, XT,SR.

WHAT STUDENTS NEED TO DO(PERFORMANCE REQUIREMENTS)

What are some of the ways to makemedication use safer?

Use generic names Medications have both a trade name (brandname) and a generic name (active ingredient). Thesame drug formulation can be produced bydifferent companies and given multiple differenttrade names. Usually the trade name appears inlarge letters on the box/bottle and the genericname is in small print. It is difficult enoughfamiliarizing oneself with all the genericmedications in use and can be almost impossibleto remember all the related trade names. Tominimize confusion and simplify communication itis helpful if staff only use generic names. However,it is important to be aware that patients will oftenuse trade names as this is what appears in largeprint on the packaging. This can be confusing forboth staff and patients. For example, consider apatient being discharged from hospital on theirusual medication but with a different trade name.The patient may not realize that the dischargemedication is the same as their pre-admissionmedication and hence continue with this as well,since no one has told them to cease it or that it isthe same as the “new” medication. It is importantto explain to patients that some medications manyhave two names.

Commercial pharmacies will sell the brand ofmedication prescribed by the doctor. Often adoctor will prescribe using a trade name as a wayof ensuring the patient is dispensed the cheapestversion of the medication available. In thissituation, patients can still be made aware of thegeneric name of the medication. Patients shouldbe encouraged to keep a list of their medicationsincluding both the trade and generic name ofeach drug.

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Tailor prescribing to individual patientsBefore prescribing a medication, always stopand think, “Is there anything about this patient thatshould alter my usual choice of medication?” Thesorts of factors to consider are allergies,pregnancy, breastfeeding, co-morbidities, othermedications the patient may be taking and size ofthe patient.

Learn and practise thoroughmedication history taking: • Include name, dose, route, frequency and

duration of every drug the patient is taking;• Enquire about recently ceased medications;• Ask about over-the-counter medications,

dietary supplements and complimentarymedicines;

• Enquire if there are any medications they havebeen advised to take but do not actually take;

• Make sure what the patient actually takesmatches your list. Be particularly carefulabout this across transitions of care. Practisemedication reconciliation on admission to andon discharge from hospital, as these are high-risk times for errors [5] due tomisunderstandings, inadequate history takingand poor communication systems;

• Look up any medications you are unfamiliarwith;

• Consider drug interactions, medications thatcan be ceased and medications that may becausing side-effects;

• Always include a thorough allergy history.Remember, when taking an allergy history, if apatient has a potentially serious allergy andthey have a condition where staff may want toprescribe that medication, this is a high-risksituation. Alert the patient and alert other staff.

Know which medications are high riskin your area and take precautions Some medications have a reputation forcausing adverse drug events. This may be due toa narrow therapeutic window, particularpharmacodynamics or pharmacokinetics or thecomplexity of dosing and monitoring.

Examples include insulin, oral anticoagulants,neuromuscular blocking agents, digoxin,chemotherapeutic agents, IV potassium andaminoglycoside antibiotics. It may be useful findingout from the pharmacist or other relevant staff inyour area what medications tend to be most oftenimplicated in adverse medication events and investtime teaching about these agents.

Know the medications you prescribe well Never prescribe a medication you do notknow much about. Encourage students to dohomework on medications they are likely to usefrequently in their practice. They should be familiarwith the pharmacology, indications,contraindications, side-effects, specialprecautions, dosage and recommended regimen.If they have a need to prescribe a medication theyare not familiar with they need to read up on themedication before prescribing. This will requirehaving ready reference material available in theclinical setting. It is better to know a few drugswell than many superficially. For example, ratherthan learning about five different non-steroidalanti-inflammatory drugs, just know one in detailand prescribe this one.

Use memory aids Perhaps in the past it was possible toremember most of the required knowledgeregarding the main medications in use. However,with the rapid growth in available medications andthe increasing complexity of prescribing, relyingon memory alone has become inadequate.

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Students need to be encouraged to have a lowthreshold to look things up, they need to becomefamiliar with using memory aids and they need toview relying on memory aids as a marker of safepractice rather than a sign that their knowledgelevel is inadequate. Examples of memory aids aretextbooks, pocket sized pharmacopoeias andinformation technology such as computersoftware (decision support) packages andpersonal digital assistants. A simple example of amemory aid is a card with all the names anddoses of medication that may be needed in thesituation of a cardiac arrest. This card can be keptin the doctor’s pocket and referred to in the eventof an emergency when there may not be time toget to a textbook or computer to check the doseof a medication. Note that memory aids are alsoreferred to as cognitive aids.

Remember the five Rs whenprescribing and administeringmedication In many parts of the world, nursing educationhas emphasized the importance of checking the“five Rs” before administering a medication. Thefive Rs are: right drug, right route, right time, rightdose and right patient. This is just as relevant fordoctors, both when prescribing and administeringmedication. Two additions to the five Rs in use areright documentation and the right of a staffmember, patient or carer to question themedication order.

Communicate clearly It is important to remember that safemedication use is a team activity that alsoincludes the patient. Clear unambiguouscommunication will help to minimize assumptionsthat can lead to error. A useful maxim toremember when communicating aboutmedications is to “state the obvious” as oftenwhat is obvious to the doctor is not obvious to thepatient or the nurse.

Remembering the 5 Rs is a useful way ofremembering the important points about amedication that need to be communicated. Forexample, in an emergency situation a doctor mayneed to give a verbal drug order to a nurse, “Canyou please give this patient 0.3mls of 1:1000epinephrine intramuscularly as soon as possible?”is much better than saying, “Quick, get someadrenaline”.

Another useful communication strategy is to“close the loop”. This decreases the likelihood ofmisunderstanding. In our example, the nursewould close the loop by saying, “Okay, so I willgive the patient 0.3mls of 1:1000 epinephrineintramuscularly as soon as possible”.

Develop checking habits It is helpful to develop checking habitsearly. To do this they need to be taught atundergraduate level. An example of a checkinghabit is to always read the label on the ampoulebefore drawing up a medication. If checkingbecomes a habit, then it is more likely to occureven if the clinician is not actively thinking aboutbeing vigilant.

Checking needs to be part of prescribing andadministration. You are responsible for everyprescription you write and drug you administer.Check the 5 Rs for allergies. High-riskmedications and situations require extra vigilancewith checking and double-checking, for example,using very potent emergency drugs in a critically illpatient. Checking on colleagues’ actions as wellas your own actions contributes to effectiveteamwork and provides another safeguard.

Remember that computerized prescribing doesnot remove the need for checking. Computerizedsystems solve some problems (e.g. illegiblehandwriting, confusion around generic and tradenames, recognizing drug interactions), but present

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a new set of challenges. [6]Some useful maxims regarding checking:• Unlabelled medications belong in the bin.• Never administer a medication unless you are

100% sure you know what it is.

Encourage patients to be activelyinvolved in their own care and themedication use process: • Educate your patients about their

medication and any associated hazards; • Communicate plans clearly with patients.

Remember that the patient and their familyare highly motivated to avoid problems, so ifthey are made aware that they have animportant role to play in the process, they cancontribute significantly to improving the safetyof medication use;

• Information can be both verbal and writtenand should cover the following aspects: - name; - purpose and action of the medication; - dose, route and administration schedule;- special instructions, directions and

precautions;- common side-effects and interactions;- how the medication will be monitored.

• Encourage patients to keep a written recordof the medications that they take and detailsof any allergies or problems with medicationsin the past. This list should be presentedwhenever they interact with the health-caresystem.

Report and learn from medicationerrors Discovering more about how and whymedication errors occur is fundamental toimproving medication safety. Whenever anadverse drug event or near miss occurs there isan opportunity for learning and improving care. Itwill be helpful for your students if they understandthe importance of talking openly about errors and

are aware of what processes are in place in yourarea to maximize learning from error and progressin medication safety.

Safe practice skills for medicalstudents to develop practice Although medical students are generally notpermitted to prescribe or administer medicationuntil after graduation, there are many aspects ofmedication safety that students can startpractising and preparing for. It is hoped that thefollowing list of activities can be expanded upon atmultiple stages throughout a medical student’straining. Each task on its own could form thebasis of an important educational session (lecture,workshop, tutorial). Thorough coverage of thesetopics is beyond the scope of an introductorysession to medication safety.

An understanding of the inherent hazards of usingmedicines will affect how a clinician performsmany daily tasks. Below are examples of what asafety conscious clinician will do.• Prescribing: Consider the 5 Rs, know the

drugs you prescribe well, tailor your treatmentdecisions to individual patients, considerindividual patient factors that may affectchoice or dose of medication, avoidunnecessary use of medicines and considerrisk benefit ratios;

• Documentation : Clear, legible,unambiguous documentation. Those whostruggle to write neatly should print. Considerthe use of electronic prescribing if available.Include patient, dose, drug, route, time andschedule as part of documentation;

• Use of memory aids: Have a low thresholdto look things up, be familiar with availablememory aids, look for and use technologicalsolutions if available and effective;

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• Teamwork and communicationsurrounding medication use: Rememberthat drug use is a team activity, communicatewith the other people involved in the processand make sure that false assumptions are notbeing made. Be on the look out for errors andencourage the rest of the team to be vigilantof their own and others actions;

• Medication administration: Be familiar withthe hazards and the safety precautions ofadministering medication by different routes—oral, sublingual, buccal, inhaled, nebulized,transdermal, subcutaneous, intramuscular,intravenous, intrathecal, per rectum and pervaginam. Check the 5 Rs wheneveradministering a medication;

• Involve and educate patients about theirmedications: Look for opportunities andways to help patients and carers helpthemselves to minimize errors;

• Learn and practise drug calculations: Befamiliar with how to manipulate units, adjustvolumes, concentrations and doses. In high-stress and or high-risk situations considerways to decrease the chance of a calculationerror such as using a calculator, avoidingdoing sums in your head (use pen andpaper), asking a colleague to also perform thecalculation and see if you concur and useavailable technology;

• Performing a medication history: Alwaystake a thorough medication history beforeprescribing and regularly review patients’medication lists, especially patients onmultiple medications. Cease all unnecessarymedications. Always consider medication asa possible cause of symptoms during thediagnostic process;

• Performing an allergy history: Always askabout allergies before prescribing amedication. If a patient has a serious allergy,stop and think if the patient is at risk ofsomeone wanting to prescribe the medication

they are allergic to. For example, if acommunity doctor sends a patient to hospitalwith suspected appendicitis and the patienthas a serious penicillin allergy, it is possiblethat there will be some momentum within thehospital to give the patient penicillin. In thissituation, it is important to emphasize theallergy in communication with the hospitalstaff, warn the patient that the usual treatmentfor appendicitis involves penicillin-basedantibiotics and encourage the patient to bealert to what medication they are being givenand to speak up if someone tries to give thema penicillin;

• Monitoring patients for side-effects: Befamiliar with the side-effects of themedications you prescribe and be proactivein looking for them. Educate patients aboutpotential side-effects, how to recognize themand appropriate actions should they occur.Always consider medication side-effects aspart of the differential diagnosis whenassessing patients with undifferentiatedclinical problems;

• Learn from medication errors and nearmisses: Learn from errors throughinvestigation and problem solving. If an errorcan occur once it could occur again.Consider strategies to prevent recurrence oferror at both an individual practitioner leveland an organizational level. Be familiar withhow to report errors, adverse reactions andadverse events involving medication.

Summary Slide Medications can greatly improve health whenused wisely and correctly. Nevertheless,medication error is common and is causingpreventable human suffering and financial cost.Remember that using medications to helppatients is not a risk-free activity. Know yourresponsibilities and work hard to make medicationuse safe for your patients.

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HOW TO TEACH THIS TOPIC

Teaching strategies/format

There are a variety of ways to teach medicalstudents about medication safety and acombination of approaches is likely to be mosteffective.

Options include: interactive lectures, small groupdiscussions, PBL, practical workshops, tutorials,project work including tasks to be undertaken inthe clinical environment and at the bedside, onlinelearning packages, reading and case analysis.

Lecture presentation and/or groupdiscussion

The PowerPoint presentation included in thispackage is designed for use as an interactiveintroductory lecture to medication safety or ateacher-led small group discussion. It can bereadily adjusted to be more or less interactive, andcan potentially be adapted to your clinical settingif you include local examples, local issues andlocal systems. There are a series of questionsinterspersed throughout the presentation toencourage students to actively engage with thetopic and also short cases with questions andanswers that could be embedded in the lecture orprovided for the students as a separate exercise.

Below are listed some other educational methodsand ideas to consider using for teaching onmedication safety.

Problem-based learning Use cases that raise issues relevant to

medication safety.

Online activities Suggested activities include:• responding to reflective questions after

reading through a case;

• learning about high-risk medications; • working through a drug calculations training

package.

Teaching and learning activities

Practical workshops Suggested topics include: • drug administration;• prescribing;• drug calculations.

Project work: Suggested topics include:

• interview a pharmacist to find out what errorsthey commonly see;

• accompany a nurse on a drug round;• interview a nurse or doctor who administers a

lot of medication (e.g. an anaesthetist) abouttheir experience and knowledge ofmedication error and what strategies they useto minimize the chance of making a mistake;

• research a medication that has a reputationfor being a common cause of adverse eventsand presenting what has been learnt to fellowstudents;

• prepare a personal formulary of medicationslikely to be commonly prescribed in the earlypostgraduate years;

• perform a thorough medication history on apatient on multiple medications—do somehomework to learn more about each of themedications, then consider potential side-effects, drug interactions and if there are anymedications that could be ceased for yourpatient; discuss your thoughts with apharmacist or doctor and share what youhave learnt with fellow students;

• find out what is meant by the term“medication reconciliation” and talk tohospital staff to find out how this is achievedat your hospital; observe and, if possible,participate in the process during admission


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and discharge of a patient and consider howthe process may prevent errors and alsowhether there are any gaps or problems withthe process.

Role plays Supplied by Amitai Ziv, The Israel Centre forMedical Simulation, Sheba Medical Centre, TelHashomer, Israel.

Scenario IErroneous administration of drugs

Description of event During the early hours of the morning shift, themorning shift nurse administered subcutaneousregular insulin 100 units, instead of 10 units aswas written in the physician’s order. The errorstemmed from the physician’s illegiblehandwriting.

The patient suffered from dementia, wasuncooperative and seemed to be asleep. Duringthe nurse’s regular checkup, she discovered thepatient to be completely unresponsive. A bloodtest confirmed that the patient was in a state ofhypoglycemic shock. The on-call physician wascalled, and the error was discovered.

The patient was treated with an infusion ofglucose 50% IV. A crash cart was brought to thepatient’s room to be on hand. The patientrecovered within a few minutes, woke up andbegan behaving normally.

Role playing actor Later on in the morning shift, the patient’s son, alawyer, comes to visit his father. Looking agitated,he turns to the nurse asking, “What happened tomy father?” His father’s room-mate told him therewas a problem and there were many people at hisfather’s bedside at the beginning of the morningshift. The nurse responsible for the error and care

of the patient is called to speak with the patient’sson.

If the nurse explains the chain of events, takesresponsibility for and admits her error, the patient’sson is not placated and retorts, “Is that the level ofcare my father has been receiving?”, “What kindof nurses work in this ward?”, “I won’t have it, Iwill take action!”, “I demand to speak to the chiefor head physician immediately!”, “I demand to seethis event’s report!”. Needless to say, if the nursedoes not explain the error and its details, thepatient’s son is upset and unwilling to accept anykind of explanation.

A physician passing by overhears theconversation and enters the room.

The physician will enter the room if the actor askshim to. If the actor does not request the physician,the physician will enter the room afterapproximately 8 minutes (12-minute scenario).The physician will enter the room and ask aboutlast night. The nurse will update him as to thismorning’s events and her conversation with thepatient’s son (either in his presence or not,depending on the physician and nurse).

Role playing actor: descriptionRY, 45 years old, is a well-dressed lawyer. Hevisits with his father whenever possible. He doesnot attend to his father; rather, he hovers over himwith unrest. He is interested in everything goingon around him, but is having difficulty acceptinghis father’s new medical state: confused,neglected and a bit sunken. He really wants tohelp, but does not know with what. Aconversation with the social worker reveals thatpreviously there was never a need for him to carefor his father, but ever since his mother fell andbroke her leg and his father’s situation hasdeteriorated, the burden of their care rests on hisshoulders alone.


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Actor tipsThe actor must intervene; complain to the headphysician of a cover-up and omission of facts;threaten with negative publicity (going to thepress) (i.e. “You almost killed him! You’re lucky itdidn’t end that way!”)

Scenario IIDeath due to erroneous medical care

Description of eventST, 42 years old, was admitted for the re-sectionof a localized, non-metastatic malignant duodenaltumour.

ST was otherwise healthy, without any family historyof malignancy. The patient had consented tosurgery and any other treatment deemed necessaryafterwards, according to pathology results.

On the morning of surgery, the patient saidgoodbye to her husband and two young children(ages 13 and 8). A small localized mass was re-sected in its entirety. The mass was sent topathology for diagnosis. Two hours into surgery,the patient showed signs of decreased saturation,tachycardia and hypotension. The patient receivedIV fluids and young, while the surgeon re-checkedthe re-section site for signs of haemorrhage, atear or an embolism. After finding nothing, thesurgeon sutured the site according to protocol.

Upon return to the ward, the patient quicklydeveloped a high fever, which remainedunchanged for a week. A medical order forantibiotics was written:

IV. GARAMYCIN 80 MGR X 3 P/D

The nurse copied the following order:IV. GARAMYCIN 80 MGR X 3 P/DOSE

The nurse who copied the order mistook the letter“D” to mean “dose”, while the physician whowrote the order actually meant “day”. Over thenext 10 days, the patient received 240 mg ofGaramycin, three times daily.

During that time, the patient began showing signsof renal failure and hearing impairment. On thetenth day of treatment, as the head nurse wastaking stock of the drugs administered, the errorwas discovered. The treatment was stopped, butthe patient’s general status deteriorated due toacute renal failure progression; 10 days later, thepatient died of generalized organ failure.

The patient’s family was critical of the nursing staffthroughout the hospitalization, blaming them formalpractice. They expressed their anger to thehead nurse and the department chief.

After the patient died, her husband asks to speakto the head nurse. He blames the nurses for theerror and malpractice that culminated in his wife’sdeath. He claims to have already discoveredwhich nurse copied the order, and threatens tosuit her.

Role playing actor: descriptionThe patient’s husband is a hard-working man,working in a store. He has difficulty providing forhis family and is struggling to make ends meet.He is an angry and restless man who has not yetcome to terms with his wife’s cancer diagnosis.He is angry with everyone and especially with thenursing staff, after his wife told him she receivedtoo many antibiotics because “the nurse couldn’tdo math”. He wants to know what killed his wife,who is at fault and who is going to pay for it. Hewants top hospital management involved, andwants help for his children. He is very upset, andshouts a lot.


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Scenario IIIPatient–caregiver communication

Description of event KL, 54 years old, has been admitted due totransient chest pain complaints. He has beenpreviously hospitalized in the ICU due to acutecoronary events. This time, preliminary test resultshave been inconclusive, and his pain is not assevere. The physician has ordered complete restand continuous 48 hour cardiac monitoring. KL isa heavy smoker, and is overweight. He has notbeen taking his prescribed medication for highblood pressure and high cholesterol.

The patient demands to be released immediately.He is afraid his hospitalization may cause him tolose his job at an automobile factory.

His anger is directed at the nurse-in-charge of theevening shift. He claims he was promised hewould be discharged and that there is no need forhim to be monitored or for complete rest. He isuncooperative. He has already convinced a youngnurse that he is right, and she has let him leavethe ward. Now, he demands to leave the wardagain and refuses to remain in his room. Hedemands to smoke and wants to be discharged.He is angry and shouting by the nurses’ station.

Assuming the nurse-in-charge insists he stay inthe ward, the patient will accuse her of beinginsensitive, and will claim the younger nurse wasnicer, more empathetic and understandingcompared to the older nurse, who is moreconservative and strictly adheres to protocol andbureaucracy.

The on-call physician is in the vicinity, but doesnot intervene and continues caring for otherpatients (some of which are near the nurses’station where the event is taking place).

Role playing actor: descriptionIrresponsible man, overweight, heavy smoker,shouts. Enjoys getting attention by shouting. He isvery concerned that he will not be able to work asmuch and may be fired. He is very afraid ofsurgery, as his best friend died on the operatingtable two years ago at the same hospital.

Scenario IVIn-patient fall

Description of event ED, 76 years old, was admitted to the ward dueto recurrent falls, reporting continuous dizzinessand instability. During his first night, he was helpedout of bed several times in order to use therestroom. At 07:30, the patient’s wife found himlying on the floor, with facial contusions and inpain. The patient does not remember whathappened.

The nurses helped the patient back into his bedand treated his lacerations. Three hours later, hewas examined by a physician, who ordered X-raysof the head, spine and limbs. The X-rays showeda fracture of the neck of the femur, as well asfractures in both hands. The patient underwentsurgery. During his recovery, the patient wasdiagnosed with right-side hemiplegia and slightaphasia.

The patient is in pain, angry and suffering. Hisentire family has been called in. Most of thepatient’s anger is directed towards the nursingstaff, which “didn’t watch over him” and “didn’tsupervise” him. The family attributes the patient’sfurther complications to the surgery.

In a heated discussion, the patient’s son accusesthe nurses of malpractice, “You’re killing my father.You do not care about him because he’s old. Youwere drinking coffee and didn’t answer my father’scalls…” His anger is directed towards the nurse-


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in-charge of the shift and the nurse in charge ofED’s care.

Role playing actor: descriptionGD, the patient’s son, is a 34-year-old taxi driverliving with his parents. He was not close to homewhen he learnt what had happened and,therefore, was only able to reach the hospital fiveto six hours after the event. He enters the wardand immediately asks to see his father and thenurse responsible for his fall. He has already beenupdated by other members of his family as to hisfather’s complications after surgery.

Actor tipsYou and your father are very close. You are a veryuptight man. Your taxi driver friends usually thinkthat medicine is not to be trusted.

TOOLS AND RESOURCESActivities that can be included as part of thePowerPoint presentation, to help make thepresentation more interesting, engaging andeffective.

Case 1 with questions for discussion: a prescribing errorA 74-year-old man sees a community doctor fortreatment of new onset stable angina. The doctorhas not met this patient before and takes a fullpast history and medication history. He discoversthe patient has been healthy and only takesmedication for headaches. The patient cannotrecall the name of the headache medication. Thedoctor assumes it is an analgesic that the patienttakes whenever he develops a headache. But themedication is actually a beta-blocker which hetakes every day for migraine. A different doctorprescribed this medication. The doctorcommences the patient on aspirin and another

beta-blocker for the angina. After commencingthe new medication, the patient developsbradycardia and postural hypotension.Unfortunately, the patient has a fall three dayslater due to dizziness on standing. He fractureshis hip in the fall.

Case 2 with questions for discussion: an administration errorA 38-year-old woman comes to the hospital with20 minutes of itchy red rash and facial swelling.She has a history of serious allergic reactions. Anurse draws up 10 mls of 1:10,000 adrenaline(epinephrine) into a 10 ml syringe and leaves it atthe bedside ready to use (1 mg in total) just incase the doctor requests it. Meanwhile, thedoctor inserts an IV cannula. The doctor sees the10 ml syringe of clear fluid that the nurse hasdrawn up and assumes it is normal saline. Thereis no communication between the doctor and thenurse at this time.

The doctor gives all 10 mls of adrenaline(epinephrine) through the IV cannula thinking he isusing saline to flush the line. The patient suddenlyfeels terrible, anxious, becomes tachycardic andthen becomes unconscious with no pulse. She isdiscovered to be in ventricular tachycardia, isresuscitated and fortunately makes a goodrecovery. Recommended dose of adrenaline(epinephrine) in anaphylaxis is 0.3–0.5 mg IM. Thiswoman received 1 mg IV.

Case 3 with questions for discussion: a monitoring errorA patient is commenced on oral anticoagulants inhospital for treatment of a deep venousthrombosis following an ankle fracture. Theintended treatment course is three to six months.However, neither patient nor community doctorare aware of the planned duration of treatment.Patient continues medication for several years,being unnecessarily exposed to the increased risk

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of bleeding associated with this medication. Thepatient is prescribed a course of antibiotics for adental infection. Nine days later the patientbecomes unwell with back pain and hypotension,a result of a spontaneous retroperitonealhaemorrhage, requiring hospitalization and ablood transfusion. Blood coagulation test revealsa grossly elevated result; the antibiotics havepotentiated the therapeutic anticoagulant effect.

TOOLS AND RESOURCES

WHO patient safety solutionsThese are summary documents detailing solutionsfor patient safety problems. A number of themconcern medication issues:Solution 1 – look-alike, sound-alike medicationnamesSolution 5 – control of concentrated electrolytesolutionSolution 6 – assuring medication accuracy attransitions in careSolution 7 – avoiding catheter and tubingmisconnectionSolution 8 – single use of injection devices

These documents can be found atwww.who.int/patientsafety/solutions/en/.

The web site www.webmm.ahrq.gov has casearchives that can be used for potential casestudies that may be helpful in your teaching.

Institute for Safe Medication Practices atwww.ismp.org.

National Patient Safety Agency atwww.npsa.nhs.uk.

Educational DVDs Beyond Blame documentary. This DVD

runs for 10 minutes and is a powerful way toengage students in the issue of medication safety.

It consists of a doctor, a nurse and a pharmacisttalking about serious medication errors they havebeen involved in. This DVD is available forpurchase through the Institute for Safe MedicationPractices—Preventing Medication Errors atwww.ismp.org

WHO Learning from error workshop includes aDVD depiction of a medication error – theadministration of intrathecal vincristine. The DVDillustrates the multifactorial nature of error.

Books Vicente K. The human factor. London,

Routledge, 2004:195–229.

Cooper N, Forrest K, Cramp P. Essential guide togeneric skills. Blackwell Publishing, 2006.

Institute of Medicine. Preventing medicationerrors: quality chasm series. Washington, DC,National Academy Press, 2006(http://www.iom.edu/?id=35961).

HOW TO ASSESS THIS TOPIC

Assessment strategies/formatsA variety of assessment methods can be used toassess medication safety knowledge andperformance elements including:• MCQs;• drug calculation quiz;• short answer questions;• written reflection on a case study involving a

medication error,iIdentifying the contributingfactors and considering strategies to preventrecurrence;

• project work with accompanying reflection onlearning outcomes of the activity;

• OSCE—potential stations include;- perform a medication and allergy history;- administer a medication checking the 5 Rs

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and for allergies;- prescribing exercises;- educate a patient about a new medication.

Note that several of these potential assessmenttopics are not covered in detail in theaccompanying PowerPoint presentation onintroduction to medication safety. They areincluded here as ideas for assessment in the areaof medication safety on the assumption thatstudents would have additional teaching on theseparticular aspects of medication safety.

HOW TO EVALUATE THIS TOPIC

Evaluation is important in reviewing how ateaching session went and how improvementscan be made. See the Teacher’s Guide (Part A) fora summary of important evaluation principles.

References1. World Health Organization. The conceptual

framework for the international classificationfor patient safety. Geneva, World HealthOrganization, World Alliance for PatientSafety, 2007.

2. Institute of Medicine. Preventing medicationerrors. Report brief. Washington, DC, Instituteof Medicine, National Academy Press, July2006.

3. Kohn LT, Corrigan JM, Donaldson MS, eds.To err is human; building a safer healthsystem. Washington, DC, Committee onQuality of Health Care in America, Institute ofMedicine, National Academy Press, 1999.

4. Runciman WB et al. Adverse drug events andmedication errors in Australia. InternationalJournal for Quality in Health Care, 2003,15(Suppl. 1):49–59.

5. Vira T, Colquhoun M, Etchells E. Reconcilabledifferences: correcting medication errors athospital admission and discharge. Quality &Safety in Health Care, 2006, 15(2):122–126.

6. Koppel R, Metlay JP, Cohen A. Role ofcomputerised physician order entry systemsin facilitating medication errors. Journal of theAmerican Medical Association, 2005,293(10):1197–1203.

SLIDES FOR TOPIC 11: IMPROVINGMEDICATION SAFETY

Didactic lectures are not usually the best way toteach students about patient safety. If a lecture isbeing considered, it is a good idea to plan forstudent interaction and discussion during thelecture. Using a case study is one way togenerate group discussion. Another way is to askthe students questions about different aspects ofhealth care that will bring out the issues containedin this topic such as the blame culture, nature oferror and how errors are managed in otherindustries.

The slides for topic 11 are designed to assist theteacher deliver the content of this topic. The slidescan be changed to fit the local environment andculture. Teachers do not have to use all of theslides and it is best to tailor the slides to the areasbeing covered in the teaching session.


topic 11: improving medication safety - world health organization

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