Harm through medication errorPresentation Transcript
Harm Through Medication Errors
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
Top 20 Medications account for about 80% of Harmful Incidents
Top Ten Medication Errors
Potassium Cl (2.2%)
Data: ISMP Canada Data: USP Acute Hospital Care
Most Common ADE & Reasons
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)
Mapping Over Comparison
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.
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
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
Accountability includes anyone who had any influence with the error
This sets the stage for broader solutions!
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.