Errors, Omissions, And Duplication - NAPLEX

Reconcile medications and request an order if clinically appropriate. Facilitates continuity of care through reconciliation, addressing potential oversights in admission orders.

Omission error. Indicates a breakdown in administration without documented rationale, potentially leading to treatment gaps.

Duplication error (double administration). Arises from redundant administration due to communication or system failures, risking overdose.

Do not guess; clarify with prescriber before dispensing/verification. Prevents misinterpretation risks by requiring clarification to ensure accurate medication delivery.

Dispensing error (wrong drug; look-alike/sound-alike). Common with look-alike/sound-alike drugs, preventable by enhanced verification and storage practices.

Clarify route with prescriber before dispensing. Ensures the medication is administered correctly by confirming the appropriate delivery method prior to release.

Hold dispensing and clarify the dose with the prescriber. Prevents potential under- or overdosing by verifying the intended dosage to ensure safe and effective therapy.

Unnecessary duplicate therapy with same or similar pharmacologic effect. Involves prescribing multiple agents with overlapping effects unnecessarily, increasing risk of adverse reactions without benefit.

A scheduled dose is not given and is not clinically justified. Represents a failure in the administration process without valid justification, potentially disrupting therapeutic outcomes.

Medication dispensed differs from what was prescribed. Involves pharmacy staff selecting, preparing, or labeling medication incorrectly, deviating from the prescriber's order.

Do not dispense; obtain a valid prescriber authorization. Maintains legal and safety standards by requiring authentication to prevent unauthorized or fraudulent prescriptions.

Clarify intended quantity or days supply with the prescriber. Ensures compliance with regulations and matches the dispensed amount to the therapeutic need for outpatient care.

Duplication/continuation error (inappropriate continuation). Stems from failure to update records, resulting in unnecessary or potentially harmful continued therapy.

An error detected and corrected before reaching the patient. Highlights opportunities for system improvements by identifying errors intercepted before patient exposure.

Patient harm resulting from medication use, including medication errors. Encompasses harm from both preventable errors and inherent drug risks, informing safety protocols.

Clarify frequency with prescriber before dispensing. Avoids risks of toxicity or subtherapeutic effects by confirming proper dosing intervals with the prescriber.

Dispensing error (incorrect directions on label). Leads to patient confusion or incorrect self-administration due to labeling discrepancies from the original order.

Prescribing error (contraindication/allergy). Happens when medication is ordered despite known patient risks, such as documented allergies or contraindications.

Dispensing error (wrong dosage form/release type). Results from substituting incorrect formulations, altering drug release and therapeutic efficacy.

Duplication error (therapeutic duplication of RAAS blockade). Involves concurrent use of similar-class agents, elevating risks like hyperkalemia without therapeutic advantage.

Duplication error (duplicate order entry). Occurs due to redundant order entry in systems, leading to excessive dosing and potential hypoglycemia.

Incorrect drug, dose, route, frequency, or directions in the prescription. Occurs during the prescribing phase when the prescriber specifies inappropriate medication details, leading to potential harm if not intercepted.

Duplication/continuation error (failure to discontinue). Results from ineffective communication of discontinuation, leading to unwarranted medication exposure.

Noxious, unintended response at normal doses (not necessarily an error). Refers to inherent drug responses not tied to errors, distinguishing from preventable medication mishaps.