Timothy S. Lesar

Tenfold Medication Dose Prescribing Errors

BACKGROUND: Tenfold errors in medication dosing continue to occur despite being a well-recognized risk, particularly to pediatric patients. Few systematic evaluations of the characteristics and causes of tenfold medication dosage prescribing errors have been performed. OBJECTIVE: To identify and quantify the characteristics of tenfold medication dosage prescribing errors. DESIGN: Evaluation of 200 consecutively detected medication orders with tenfold errors in dosing in a 631-bed tertiary-care teaching hospital. MAIN OUTCOME MEASURES: Type, frequency, characteristics, causes, enabling factors, and potential for adverse effects of tenfold medication dosage prescribing errors. RESULTS: Two hundred cases of tenfold prescribing errors were detected over an 18-month period. Overdoses were prescribed in 61% of the cases and underdoses in 39% of the cases. Ninety (45%) of the errors were rated as potentially serious or severe; 19.5% of the errors ocurred in pediatric patients. Levothyroxine accounted for 19% of all errors. As a class, antimicrobials, cardiovascular agents, and central nervous system agents each accounted for ≥15% of errors. Errors were associated with multiple zeroes in the dose (45%), use of equations or calculations to determine dose (27% total cases, 92.3% of pediatric cases), dose amount less than 1 (25%), and expression of measure conversion (23%). The tenfold errors were produced by a misplaced decimal point in 87 cases (43.5%), adding an extra zero in 63 cases (31.5%), and omitting a zero in 50 cases (25%). Factors identified as enabling a tenfold error to be carried out as ordered were a wide dose range for the drug (76.5%), medication ordered and able to be given by injection (42%), ability to give ordered dose as ≤5 solid oral dosage forms (36%), and availability of an oral liquid dose form (15%). CONCLUSIONS: Prescribing of tenfold medication dose errors is common and is associated with identifiable risk factors. Implementing commonly recommended medication safety processes are likely to reduce risk to patients from such errors. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.

Prescribing Errors Involving Medication Dosage Forms

CONTEXT: Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE: To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms. DESIGN: Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES: Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS: A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS: Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.

Antiretroviral Prescribing Errors in Hospitalized Patients

OBJECTIVE: To quantify error type and frequency and to identify factors associated with antiretroviral prescribing errors in hospitalized HIV-infected patients. DESIGN: Systematic evaluation of all medication prescribing errors involving antiretroviral medications between January 1, 1996, and October 31, 1998. Each error was concurrently evaluated for the potential to result in adverse patient consequences. Each error was retrospectively evaluated by three pharmacists and assigned a “likely related factor.” SETTING: A 631-bed tertiary care teaching hospital. PARTICIPANTS: All physicians prescribing antiretroviral medications during the study period and all staff pharmacists involved in the routine review of medication orders. MAIN OUTCOME MEASURES: Type and frequency of prescribing errors involving antiretroviral medications and frequency of association of likely related factors to errors. RESULTS: A total of 108 clinically significant prescribing errors involving antiretrovirals were detected during the 34-month study period. The most common errors were overdosing and underdosing. Overall, errors occurred in 5.8% of admitted patients prescribed antiretroviral medications. The rate of error increased from 2% of admissions in 1996 to 12% of admissions in 1998. The most common likely related factors associated with errors were confusion/lack of familiarity regarding appropriate dosing frequency (30.3%) or dosage (25.5%), and confusion due to need for multiple dosage units per dose (13%). CONCLUSIONS: Hospitalized patients taking antiretrovirals are at risk for adverse outcomes due to prescribing errors. This risk has increased with the rising complexity of antiretroviral drug regimens. A limited number of factors are associated with a large proportion of antiretroviral prescribing errors. This information should be considered in the development of medication error prevention strategies necessary to prevent adverse patient outcomes resulting from such errors.

Antimicrobial Drug Delivery to the Eye

A major obstacle in the treatment of ocular infections is the difficulty in obtaining adequate antimicrobial drug concentration at the site of infection. This article reviews the pharmacokinetic principles of ophthalmic drug delivery as it pertains to antimicrobial therapy. The administration of antimicrobials by topical application, subconjunctival injection, intravitreal injection, vitreous replacement fluid, and systemic administration are addressed. Representative data on the intraocular penetration of antimicrobials as well as recommended doses of drugs for ocular infections are presented.

Preventing Medication Prescribing Errors

Medication errors may arise in the manufacture, preparation, distribution, and administration of drugs. Physician prescribing errors are of particular importance as such errors have been associated with significant adverse patient outcomes. The pharmacist plays an important role in preventing such errors from reaching the patient. The purpose of this article is to define and illustrate the various error types and the mental attitudes that cause individuals to prescribe errant orders. Through better understanding of the cause of prescribing errors, pharmacists may be able to improve the error prevention services they provide. Based on the error types discussed and their causes, recommendations are proposed to decrease the frequency of such errors and thereby improve the quality of patient care.

Dosing adjustment of 10 antimicrobials for patients with renal impairment.

Objective: To describe a program of creatinine clearance–based dosage adjustment of 10 renally eliminated antimicrobial agents and to discuss the utility of such a program in a hospital as a method of quality assurance (by ensuring that patients with renal impairment receive generally accepted dosage adjustments), based on pharmacodynamic principles. Methods: Consecutive patients prescribed any of 10 targeted renally eliminated antibiotics were included. Recommendations for dosage adjustment were made to the prescriber based on a calculated creatinine clearance. Additional adjustments in drug therapy were performed, including dosage recommendations of nontargeted drugs, simplification of antibiotic regimens, and conversion of intravenous to oral therapy. A cost analysis was performed. Results: During a 6-month study period, 160 dosage changes (7.6% of total number screened) were recommended in 137 patients receiving the targeted antimicrobial agents. Prescribers accepted 147 recommendations (91.9%). A dosage change recommendation was necessary more than 12% of the time for acyclovir, ceftazidime, and imipenem/cilastatin. A cost avoidance of

The VHA New England Medication Error Prevention Initiative as a Model for Long-Term Improvement Collaboratives

11 702.08 was realized. Ancillary drug recommendations that were offered and accepted during the program realized a cost avoidance of

A standardized approach to pediatric parenteral medication delivery

6613.75. Conclusions: This dosage adjustment program using pharmacodynamic principles was successful in optimization of dosing, potential minimization of morbidity caused by excessive dosing, and demonstration of direct and potentially indirect cost avoidance. A dosing program for patients with renal impairment would be of benefit to other clinicians and institutions seeking to optimize patient care.

Analgesic Prescribing Errors and Associated Medication Characteristics

BACKGROUND Quality improvement collaboratives (QICs) are a widely applied strategy for implementing change in health care organizations. Alternative collaborative methodologies were compared to gain insight into the elements important for QIC success. METHODS A modified version of a previously described QIC evaluation tool was used to assess the methods and characteristics of the Medication Error Prevention Initiative (MEPI) and to compare MEPI with two other long-term ongoing QICs--the Vermont-Oxford Networks Neonatal Intensive Care QIC and the Northern New England Cardiovascular Disease Study Group, and the shorter-term Breakthrough Series QICs of the Institute for Healthcare Improvement (IHI). RESULTS The modified QIC assessment tool was a useful framework for QIC assessment and comparison. The MEPI differed in scope of topic, team members, and the method for learning about and making improvements. CONCLUSIONS Long-term QIC methods such as those used by MEPI may be particularly applicable when QICs address broad, complex, comprehensive, or organizationwide improvement needs.

Medication Prescribing Errors Involving the Route of Administration

Delivering medications safely to hospitalized pediatric patients presents a significant challenge. Current JCAHO standards require safe medication practices, including the standardization of parenteral medications and solutions. Our institution convened a pediatric process improvement team (consisting of pharmacists, nurses, physicians, and administrators) to address deficiencies in our medication use process. This article describes the standardized parenteral medication processes that this committee ultimately endorsed. The new system was designed to control, simplify, and standardize each major step in the medication use process, from prescribing through administration. The system involved defining and standardizing prescribing practices, which then allowed for reduced variability and the preplanning of drug preparation and administration processes. To ease transition and simplify implementation, three phases of the process were introduced in a step-by-step manner: phase 1, continuous infusions; phase 2, intermittent IV doses; and phase 3, bulk IV fluids. Time to implementation included 6 months of preparation prior to phases 1 and 2 and approximately another year to phase 3. The standardized pediatric parenteral medication process has resulted in improved patient safety and operational efficiency. It has also eliminated the “Rule of six” method of drug preparation and administration.