Your SlideShare is downloading. ×
Harm through medication error
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Harm through medication error

1,137
views

Published on

Published in: Health & Medicine

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,137
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
29
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Harm Through Medication Errors
  • 2. Overview
    • Common Medication Errors
    • Steps to Avoid and Eliminate Errors
    • Strategies to Communicate Effectively
    • Ways to Reduce Stress
  • 3.
    • 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. 
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. Mapping Over Comparison
    • Errors
    • Insulin
    • Narcotics
    • Anticoagulants
    • Antibiotics
    • Furosemide
    • ADE
    • Insulin
    • Narcotics
    • Anticoagulants
    • Antibiotics
    • NSAIDs
  • 8. 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.
  • 9. 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!
  • 10. System Errors
    • Lighting
    • Staffing
    • Orders
    • Doses
    • Drug Labels
  • 11. 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!!
  • 12.
    • 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.
  • 13.