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Medication error presentation


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Hello Everyone :)
I hope this presentation will help us to:
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Identify weaknesses or failures in key elements of the medication-use system.
Select effective risk-reduction strategies to prevent medication errors.

Published in: Health & Medicine
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Medication error presentation

  1. 1. MEDICATION ERROR AGA KHAN HOSPITAL (22-JAN-2014) Presentation By: Beenish Iqbal Arain
  2. 2. Objectives  Definitions  Causes  Stages of Medication error  How to decrease Medication error Dr:Beenish Iqbal Arain
  3. 3. Medication Error Definition  Medication errors, broadly defined as any error in the prescribing, dispensing, or administration of a drug,  Medical errors are often described as human errors in healthcare > Such events may be related to: 1) professional practice 2) health care products 3) Procedures and systems 4) product labeling, packaging, and nomenclature 5) dispensing 6) distribution 7) administration 8) education 9) monitoring Dr:Beenish Iqbal Arain
  4. 4. Some reasons errors occur  verbal orders  poor communications within healthcare team  poor handwriting  improper drug selection  missing medication  drug interactions  availability of floor stock (no second check)  look alike / sound alike drugs  hectic work environment  lack of computer decision support Dr:Beenish Iqbal Arain
  5. 5. Stages of Medication Error  Phase 1- Ordering/Prescribing  Phase 2- Dispensing  Phase 3- Administration  Phase 4- Monitoring DR:Beenish Iqbal Arain
  6. 6. Ordering/prescribing  inadequate knowledge about drug indications and contraindications  not considering individual patient factors such as allergies, pregnancy, co-morbidities, other medications  wrong patient, wrong dose, wrong time, wrong drug, wrong route  inadequate communication (written, verbal)  documentation - illegible, incomplete, ambiguous  mathematical error when calculating dosage  incorrect data entry when using computerized prescribing e.g. duplication, omission, wrong number  DR:Beenish iqbal Arain
  7. 7. Prescription error example
  8. 8. Dispensing  inexperience  rushing  doing two things at once  interruptions  fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check  lack of checking and double checking habits  poor teamwork and/or communication between colleagues  Too much phone calls Dr:Beenish Iqbal Arain
  9. 9. Dispensing error example
  10. 10. Look alike/ sound alike Sound alike Look alike  Zantac/Zyrtec  Rotavir/Ritnovir  Folic acid/ Folinic acid  ephederine/ epinephrine  Doxorubicin/ Daunorubicin  Celebrex/ cerebryx DR:Beenish iqbal Arain  Cyclogest/paracup
  11. 11. Look alike examples
  12. 12. Administration  wrong patient  wrong route  wrong time  wrong dose  wrong drug  omission, failure to administer  inadequate documentation
  13. 13. Administration error example
  14. 14. Monitoring  lack of monitoring for side-effects  drug not ceased if not working or course complete  drug ceased before course completed  drug levels not measured, or not followed up on  communication failures Dr:Beenish Iqbal Arain
  15. 15. What Can You Do To Decrease Medication Errors?  Check and double check, if in doubt check it out, again!  Follow the 5 R’s: right patient, right drug, right dose, right time, right route  Never assume, “pharmacy put the medication in the drawer so this must be right”, pharmacy makes errors too.  Never assume, “the resident ordered this large dose so it must be right”, Residents make errors too.  Know the correct mg/kg dose of medications you are administering.  Know why you are giving the medication, the expected action, and any potential side effects. DR:Beenish Iqbal Arain