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Medication error
Medication error
Medication error
Medication error
Medication error
Medication error
Medication error
Medication error
Medication error
Medication error
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Medication error

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  • 1. Medication Error
    Detection and prevention
  • 2. What is medication Error
    A medication error is an preventable event that may cause or lead to inappropriate medication use or patient while the medication is in the control of the health care professional, patient, or consumer.
    Such events may be related to
    • professional practice,
    • 3. health care products,
    • 4. producers and systems,
    • 5. prescribing; order communication ;
    • 6. product labelling packaging and nomenclature;
    • 7. compounding
    • 8. dispensing
    • 9. distribution
    • 10. administration
    • 11. education
    • 12. Monitoring
    • 13. use
  • Common types of medication errors
    The Institute for Safe Medication Practices (ISMP) identifies the following areas as potential causes of medication errors
    • Failed communication:
    • 14. handwriting and oral communications, especially over the telephone,
    • 15. drugs with similar names,
    • 16. missing or misplaced zeroes and decimal points,
    • 17. confusion between metric and apothecary systems of measure,
    • 18. use of nonstandard abbreviations
    • 19. ambiguous or incomplete orders
    • 20. Poor drug distribution practices.
    • 21. Workplace environmental problems increasing the job stress.
    • 22. Complex or poorly designed technology.
    • 23. Access to drugs by non-pharmacy personnel
    • 24. Dose miscalculations
    • 25. Lack of information to prescribers
    • 26. Lack of patient information
    • 27. Lack of patients’ understanding of their therapy
  • Causes for errors
    Too many telephone calls (62%)
    Overload/ unusually busy day (59%)
    Too many customers (53%)
    Lack of concentration (41%)
    No one available to double check (41%)
    Staff shortage (32%)
    Similar drug names (29%)
    No time to counsel (29%)
    Illegible prescription (26%)
    Misinterpreted prescription (24%)
  • 28. Types of errors are usually identifiable and can be corrected before the error reoccurs
    Incomplete patient information (not knowing about patients’ allergies, other medicines they are taking , previous diagnoses, and lab results for example)
    Unavailable drug information (such as lack of up-to date warnings)
    Miscommunication of drugs orders, which can involve poor handwriting , confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations.
    Lack of appropriate labelling as a drug is prepared and repackaged into smaller units
    Environmental factors, such as lighting, heat, noise, and interruptions that can distract health professionals from their medical tasks.
  • 29. Medication error rate
    “ Medication error rate” is determined by calculating the percentage of errors.
    Medication Error Rate =
    Number of Errors Observed
    -------------------------------------- X100
    Opportunity of Errors
  • 30. Root Cause analysis
    Retrospective analysis of a pharmacovigilance database allows identification of the classes of medication that are most often involved in preventable suspected adverse reactions, the stage at which the error occurs during therapy and the types of error involved
  • 31. Methods of conducting root cause analysis
    Canadian root cause of analysis framework
    The ishikawa or fish bone diagram
    The guidelines for root cause analysis of the Massachusetts medical society
  • 32. The ishikawa or fish bone diagram
    The 8 Ms (used in manufacturing)
    Machine (technology)
    Method (process)
    Material (Includes Raw Material, Consumables and Information.)
    Man Power (physical work)/Mind Power (brain work): Kaizens, Suggestions
    Measurement (Inspection)
    Milieu/Mother Nature (Environment)
    Management/Money Power
    Maintenance
    The 8 Ps (used in service industry)
    Product=Service
    Price
    Place
    Promotion/Entertainment
    People(key person)
    Process
    Physical Evidence
    Productivity & Quality
    The 4 Ss (used in service industry)
    Surroundings
    Suppliers
    Systems
    Skills
  • 33. By Priti Gupta

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