4. CASE STUDIES
• A baby with persistent cough
brought to hospital and due
to rude behavior with his
mother, his mother did not
return with him for follow up
examination.
• A comparative analysis was
conducted among different
cancer patients for
determining thematic pattern
in perceptions and both the
result was found in a manner
of both common perspectives
and diversions too.
5. b) Illegible hand
writing and
dispensing error
• Doctors are famous
for their unreadable
writing; prescriptions
are life savior for the
patient but sometime
it become noxious to
the patient upon
certain factors.
6. 1. 73 years old man visited for
routine checkup to hospital who
was experiencing long standing
cardiac arrhythmias was
prescribed rythamol but
because of illegible writing he
was prescribed different drug.
8. 3.For the prevention of chronic
pulmonary embolism,
community pharmacist placed
the rivaroxaben prescription on
hold rather than discontinue the
order as anticoagulant clinical
staff has requested.
9. c). Medication
administration
error:
• A drug administration
error may be defined
as a variation between
the drug therapy
received by the patient
and the drug therapy
planned by the
prescriber.
10. 1. Administration error is the
most widely occur error in the
hospital system, the highest
error rate was recognizing in
injectables in intravenous route.
11. 2. In a hurry nurse forgets to
notice the don't crush warning
on the electronic medication
administration record, she
crushes the medicines and
deliver it into ng tube and the
patient died.
13. 1. After 1 to 3 months of
diagnostic delay, jury verdict
favor the defense [ 7 of 11 [65%]
defense verdicts] , after 6
months of diagnostic delay, jury
verdict was nearly evenly split
between defense verdicts,
plaintiff verdicts and out of
course settlements.
14. e) .Patient related
issues and
monitoring
therapy
• After a doctor has performed surgery or
prescribed a new drug or other treatment
to patients, they will provide follow-up care
to determine if the treatment has helped or
made it difficult to care for the patients.
Optimal treatment provides complete relief
from the symptoms of many diseases. But
even with such treatment, some patients
still have complaints. One disorder for
which patients should achieve complete
symptom relief with medication or surgery
is gastro esophageal reflux disease
(GERD).
15. 1. 12 patients with gerd are taken
and persistent complaint underwent
a semi-structured interview that
focused on patient assessment of
treatment failure, disruptions of
interactions with health services
was the most important cause of
treatment failure followed by
primary, secondary health care and
patient himself.
16. 2. A case was reported during
rapid iv administration of
vancomycin which maybe
present in histaminergic
reactions with clinical signs
ranging from mild rash, pruritus
and even shock.
17. 3. A case of fracture cerebral
infection after self massage of
the carotid sinus with pre
existing carotid artery stenosis.
18. f). Procedural
complications
[technical errors]
• As medical technology and
advancements have
brought benefits to
patients, at a same time
they also carry with them
the potential for disasters
that pose a threat to the
safety of patients but the
overall worse effect of IT
are less as compare
conventional medical
methods.
19. 1. Seven Columbian treated for
breast cancer developed
radiotherapy induced tumors
between 2008 and 2018.
21. OUTCOMES:
• Lack of security can lead to
deaths, disabilities, poor
health outcomes, increased
costs and legal problems.
22. Preventions:
Confirm that the prescription should
be correct.
Computerize the prescription
process.
The doctors and pharmacists must
be well aware of lookalike and
sounds like drugs.
Workplace should be properly
organized and patient should have
proper counseling.
Improvement in the storage of
syringes, drugs.
Improving in reading of labels and
labels should always have complete
drug strength information.
Presence of pharmacist at every
healthcare institute
23. Conclusion:
Medical errors
Improvement of outcomes
of medical errors
Role of healthcare system
Patient health and safety
