Harm through medication error

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Harm through medication error

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

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