Prescription errors and beyond-use date

Prof. Dr. Henny Lucida, Apt

Prescription errors Definition: Unintentional mistakes in the prescription, transcription, dispensing, and administration of medication

Medical Errors by Type

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
80% 20%

Prescription Errors

39%

Ordering/ Prescribing

38%

Administration

12%

Dispensing Transcribing

Other

11%

Prescription/Medication errors
SOME COMMON CAUSES OF MEDICATION ERRORS : Failed communication Poor drug distribution practices problems Dose miscaculations Drug and drug device-related problems Incorrect drug administration Lack of patient education

Types of errors

Handwriting

Drugs with similar names

Terutama yang namanya mirip: longatin largactil, epatin enatin, difenilhidantoin - difenilhidramin Losec Lasix, Seldane (terfenadine)-Feldene (NSAID), taxol (anticancer)-paxil (antidepressant) Vincristin 2.0 mg 20 mg Digoxin 0.017 mg 0,17 mg

Zerroes and decimal points

Metric and apothecary systems

Supaya ada standar 1/200 grain (0,3 mg) nitroglycerin tablet menggunakan 2x1/100 grain (0,6 mg masing-masing, atau 1,2 dosis total) .

 Ambiguous or incomplete orders Cyclophosphamide dosis 4 g, 1 4 hari, maksudnya 4 gram untuk total 4 hari ( 1 gram per hari, tetapi diberikan 4 gram per hari Abbreviations D/C discharge and discontinue: digoxin, propranolol, insulin Pasien pulang, obat masih diteruskan, dikira pulang obat discontinue HS half strength,. Pasien menerima HS hora somni, hora somni dan full strength QD QID i/d (one per day) TID (tdd)

PROBLEM RELATED to DRUGS and DRUG DEVICES

Profesi

kesehatan membaca label tiga kali yaitu waktu mengambil, menggunakan dan mengembalikan. dan packaging menyebabkan medication errors.

Labeling

INCORRECT DRUG ADMINISTRATION

Walaupun dalam persiapan dispensing sudah benar tetapi masih kemungkinan terjadi kesalahan pada penggunaan obat. Untuk memperoleh pengobatan tepat pasien dengan tepat route dan tepat waktu adalah esensial. Pasien kadang kurang perhatian. Misal tetes mata, tetes hidung, tetes diminum; obat topikal diminum (vaginal tablet, suppositoria), enteral feeding dengan gasric tube diberikan iv

LACK of PATIENT EDUCATION

Farmasis mendidik pasien secara profesional merupakan hal yang penting dalam meyakinkan penggunaan obat. Pasien yang tahu penggunaan obat untuk apa, cara pemakaian, seperti apa obat tersebut, bagaimana obat bekerja sangat membantu meminimalkan tidak terjadinya medication errors Konseling dan edukasi tentang pengobatan dan semua pengelolaan obat dan penyakit sangat penting Pasien diusahakan untuk bertanya dan mendapat jawaban yang memuaskan

Prescription errors
Includes: wrong patient incorrect medication inappropriate dose wrong time wrong route of administration Wrong rate of administration

Kategori error (Feinberg, ed. Med Pass Survey, ASCP, 1993)

Omission Error Terlambat/terlalu cepat memberikan regimen dosis berikutnya Pasien membeli antibiotika tanpa resep Dosis ganda Dosis lebih besar atau lebih kecil dari yg diresepkan dokter Tidak tepat cara pemberian Laju infus kurang/lebih

Unauthorized Drug error Extra Dose Error Wrong Dose Error

Wrong Route Error Wrong Rate Error

Kategori error (Feinberg, ed. Med Pass Survey, ASCP, 1993)

Wrong Time Error Wrong Drug preparation Error Tidak tepat Interval dosis - Suspensi tidak dikocok - Sediaan sustained release dibikin puyer - Incompatible - Inadequate product packaging - Injeksi tanpa metode steril - Tidak tepat dalam menggerus obat

Wrong Administration Technique Error

Deteriorated Drug Error

Obat rusak, kadaluarsa, obat tidak disimpan di lemari es

Psychological classification of medication errors (the Lancet, vol 355, 2000)

Tipe error/mistakes Knowledge-based error Rule-based error Contoh-contoh Memberikan penisilin dan turunannya tanpa menanyakan riwayat alergi Memberikan injeksi diklofenak di paha samping bukan di gluteus

Applying a bad rule

Slips and lapses

Memberikan captopril dosis besar pada awal gejala

Slips of action (skill-based error): bermaksud meresepkan chlorpromazine tapi tertulis chlorpropamide Memberi beta blocker, tahu, tapi lupa bhw pasien penderita asma

Lapses of memory

To prevent prescription & medication errors

Five right principles: The right medication In the right dose To the right patients At the right time By the right route of administration

Guidelines to a pharmacist
1. 2.

3.

A systematic, step-by-step checking would be very helpful Make sure that the information is correctly transferred to the prescription label Make sure that the correct drug is being dispensed, whether generic or brand

Contoh Preparation error

R/ Azythromycin Ibuprofen GG Dexametason Luminal Vitamin C mf la dtd no. XII S 3 dd 1 Pro: Anak, 2 thn mg 100 mg 100 tab tab mg 30 mg 20

Contoh 2
R/ Piroksikam Licodekson Ibuprofen Dexametason no. 10 no. 10 no. 10 no. 10

Pro: S , 40 thn

Expiration date vs beyond-use date

Expiration date: a projection of the length of time the product can be expected to retain its purity and potency based on accelerated stability studies. Exp date is used for commercial products Beyond-use date: an estimate of the time interval that the compounded preparation can be expected to retain its purity and potency based on general guidelines, literature references or actual real-time stability studies using prescribed conditions

Beyond-use date
In

general: a maximum beyond-use date of 6 months is used Most pharmacists prepare or dispense small quantities of compounded products, recommend storage at room or cold temperatures

Maximum recommended beyond-use date

For nonsterile compounded drug preparation packaged in tight, light-resistant containers when stored at a controlled room temperature or as otherwise indicated: Non aqueous liquids and solid formulations: the beyond-use date should be no later than 25% of the time remaining on the original products exp date, or 6 months, whichever is earlier

Maximum recommended beyond-use date

formulations when prepared from ingredients in solid form, the beyond-use date should be no later than 14 days when stored at cold temperatures
Water-containing

Maximum recommended beyond-use date

other formulations the earlier of 30 days or the intended duration of therapy should be used
All