|
| Medication process | Sources of error | Strategies to avoid errors |
|
| (1) Prescription suggestions | (i) False dose (kidney function!)
(ii) Drug not indicated (any more)
(iii) Dangerous interactions
(iv) False application (e.g., halving slow release tablets, grinding enteric-coated tablets, etc.)
(v) Doubling prescriptions
(vi) PIM-prescriptions | See (9) |
|
| (2) Documentation | (i) No medication plan issued
(ii) Not updating the medication plan, for example, between services (admissions and transfers)
(iii) Plan not available/patients do not have the plan with them
(iv) Transcription errors
(v) Poor legibility
(vi) No documentation when issuing drug samples | (i) Tracking (patient lists for admissions and transfers)
(ii) Encouraging patient self-responsibility and self-management
(iii) Document issuing of sample packages |
|
| (3) Writing prescriptions | (i) Not considering repeat prescriptions
(ii) Dose error
(iii) Dose not recorded on the prescription
(iv) Software error or PC user error on (e.g., switches column) | (i) Telephone prescriptions/no routine filling of prescriptions
(ii) Update and check medication plan with every prescription →
(iii) Patient education: no filling of prescriptions without medication list
(iv) Checking prescription timeframe on every repeat prescription
(v) Thorough checking of prescription requests from nursing homes
(vi) Education of HCA about high risk medication |
|
| (4) Dispensing medications | (i) Mixing up brand names and generic names/discount contracts
(ii) Dangerous self-medication
(iii) Issuing medication without prescription/later presentation of prescription
(iv) Issuing of incorrect medication or incorrect dose strength | (i) Medication lists specifying the active ingredients instead of trade names.
(ii) Checking with pharmacies in the area
(iii) Advising patients to use a regular pharmacy (own choice)
(iv) Checking interactions in the pharmacy
(v) Using blister packs
(vi) “Aut idem”-prescriptions of risk medications (e.g., Marcumar, L-Thyroxin) |
|
| (5) Administration of medications | (i) Unintended nonadherence (forgotten to take medication)
(ii) Intentional avoidance/dose reduction or self-determined dose skipping
(iii) Problems with administration: swallowing, dividing tablets (phenprocoumon!), drops, inhalers, injections, patches
(iv) Unintended intake of double dose due to generic drugs/various brand names
(v) Confusing medications
(vi) Daily intake of preparations that are intended for once a week (e.g., vitamin D, Iodine, biphosphonate, methotrexate) | (i) Use combination drugs
(ii) Avoid halving doses
(iii) Intake every morning
(iv) Patient education (e.g., Education video for Marcumar patients from Göttingen Uni)
(v) Reminder for patients
(vi) Checking administration by HCA
(vii) “Money Counting Test”
(viii) Administration information from the pharmacy
(ix) Support from relatives and nursing stuff |
|
| (6) Monitoring of ADR | (i) “Prescription cascade”
(ii) Repeat prescription despite a lack of improvement
(iii) Lack of/infrequent creatinine levels control
(iv) Lack of/infrequent INR control
(v) Lack of/infrequent blood sugar levels control | (i) Planned withdrawal trials
(ii) Case-Management
(iii) Pharmacovigilance
(iv) Prescription of risk medications bound with monitoring requirements (e.g., ECG with repeat prescriptions of certain antidepressant agents) |
|
| (7) Stocktaking/inventory | (i) Lack of/incomplete assessment of self-medications
(ii) Lack of/incomplete assessment of prescriptions from other doctors
(iii) Medication from the partner taken or brought in | (i) Appointment for systematic review of medications (“Brown Bag Review”)
(ii) Reminder before appointment for patient to bring all their medications with them |
|
| (8) Patient preferences | (i) Patient insisting on/or declining a particular medication
(ii) Subjective view of intolerance
(iii) Problems with understanding due to poor education level, low intelligence, or language barriers | (i) Do not assume a medication preference/directly question patient if they have medication preferences
(ii) Relationship management so that admitting nonadherence is possible
(iii) Discuss fears/illness concept with the patient
(iv) Shared decision making
(v) Documentation when medications are declined
(vi) Prescription of risk medication on nonsubsidised forms (patient carries cost, e.g., for sleeping tablets, NSAIDs) |
|
| (9) Medication reconciliation | (i) Complete overview of medications is unknown due to prescriptions from various doctors and over-the-counter medications
(ii) Lack of specialist knowledge
(iii) Uncertainty regarding discontinuation of medications prescribed by specialist or clinics
(iv) Conflicting guidelines | (i) Online reference resources PRISCUS-List
(ii) Medication appropriateness Index (MAI) for systematic review of medications
(iii) Software for checking interactions
(iv) Binding “Disease Management Programs” with medication checks |
|
