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Harm through medication error
 

Harm through medication error

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    Harm through medication error Harm through medication error Presentation Transcript

    • Harm Through Medication Errors
    • Overview
      • Common Medication Errors
      • Steps to Avoid and Eliminate Errors
      • Strategies to Communicate Effectively
      • Ways to Reduce Stress
      • From 2001-2005, a total of 10,791 inpatient medication incident reports (including reports of near misses) have been voluntarily reported & collected by the Institute for Safe Medication Practices (ISMP) Canada
      • Of these, 465 were reported to have resulted in harm to patients, and 10 drugs accounted for 199 or 43% of these harmful incidents. 
    • Pareto’s 20/80 Principle
      • 10,791 Total Reports
      • 465 Resulted in Harm
      • 10 Medications accounted for 199 (43%) of Harmful Incidents
      • Extrapolation:
      • Top 20 Medications account for about 80% of Harmful Incidents
    • Top Ten Medication Errors
      • Insulin (4%)
      • Morphine (2.3%)
      • Potassium Cl (2.2%)
      • Albuterol (1.8%)
      • Heparin (1.7%)
      • Vancomycin (1.6%)
      • Cefazolin (1.6%)
      • Acetaminophen (1.6%)
      • Warfarin (1.4%)
      • Furosemide (1.4%)
      Data: ISMP Canada Data: USP Acute Hospital Care
    • Most Common ADE & Reasons
      • Antibiotics (9.4%)
      • Insulin (8%)
      • Anticoagulants (6.2%)
      • NSAIDs (4.6%)
      • Hydrocodone/apap (2.2%)
      • Acetaminophen (1.8%)
      • Unintentional Overdoses (40%)
      • Side Effects & Allergic Reactions
      • Older Adult Pharmacokinetics
        • 34% of all written Rxs to this group
        • Year 2000: 28.5 Rxs per person
        • Year 2010: 38.5 Rxs per person
        • 250,000 seniors are hospitalized every year due to drug reactions & interactions
      • Misuse of Medication (5 Rights)
      • Antibiotics
    • Mapping Over Comparison
      • Errors
      • Insulin
      • Narcotics
      • Anticoagulants
      • Antibiotics
      • Furosemide
      • ADE
      • Insulin
      • Narcotics
      • Anticoagulants
      • Antibiotics
      • NSAIDs
    • How Can We Prevent Errors?
      • 50% of all Errors & ADE have some form of "preventability”.
      • Many do not represent errors of commission but, rather, errors of omission.
      • Meaning someone (pharmacist, physician, patient, or the interactions between these groups) omitted the detection of certain factors that most likely led to the adverse event.
      • Omission
      • Disease state contraindicated to the drug therapy.
      • Detection of a significant drug interaction.
      • Detection of a significant drug allergy.
      • Correct dose for a specific patient.
      • Monitoring of drugs with narrow therapeutic indexes
      • Patient knowledge.
    • Systems Approach
      • Looks at the whole system not one individual
      • Failures in the design or implementation of systems:
        • Excessive reliance on memory
        • Lack of standardization
        • Inadequate access to information
        • Work schedules
      • Accountability includes anyone who had any influence with the error
      • This sets the stage for broader solutions!
    • System Errors
      • Lighting
      • Staffing
      • Orders
      • Doses
      • Drug Labels
    • Communication is Key
      • Counseling the provider and/or the patient
      • Communicating with providers:
        • Identify the issues clearly & concisely
        • Keep focused on the patient
        • Provide possible solutions
        • Ask for provider feedback
        • Document the final decision
      Be the 1st to say Hello!!
      • Conflict can hinder the discovery of medication errors
        • Opinions about patient care must be handled objectively & professionally.
        • Code of Conduct encourages behaviors that support the team, staff morale, & a sense of self-worth & safety.
    •