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What are the quality issues inPATIENT SAFETY and the potential impact of an effort to improve? Medication errors
Medical error: a preventable adverse event or near miss due to the failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim Adverse event: unintended patient harm caused by medical management rather than by a disease process, which results in a prolonged hospital stay, morbidity, or mortality Near miss: an error or mishap that had the potential to cause patient harm, but did not, either by chance or thanks to timely intervention(Cuong Pham,J., Aswani,M.S., Rosen,M., Lee,H.W., H
Systems issues that contribute tomedication errors: Lack of adequate staffing Patient acuity levels Inadequate access to policy and medication information Physical environment – ie lighting, bedside Organisational culture Organisation communication channels Organisational routines Pharmaceutical related issues Incident reporting culture
Personnel issues: Understanding of how errors occur Failure to adhere to policy and procedure documents Number of hours on shift Distractions Lack of knowledge about medications Dosage calculation Workload Care delivery method
The nurses’ role in preventingmedication errorsIn administering any medication, nurses and midwives are required to: Know the relevant legislation relating to medication administration Have adequate knowledge of the medication, its therapeutic purpose, usual dose, frequency and route of administration, specific precautions, contra-indications, side effects and adverse reactions. Nurses and midwives should also be aware of the correct storage requirements for medications. Adhere to required checking policies and procedures developed by agencies. http://www.nursing.health.wa.gov.au/docs/nmo/NMBWA_M edication_Management_Guidelines.pdf
Systems implemented to preventmedication errors : Computerized physician order entry (CPOE) systems and clinical decision support systems (CDSS) Bar-coding systems Medication Reconciliation Standardised ordering and administration Training, education, and organisational interventions
Trigger Tool for Measuring AdverseDrug Events – Institute forHealthcareThe World Health Organization (WHO) Collaborating Centres for International Drug Monitoring defines an adverse drug event (ADE) as: “Noxious and unintended and occurs at doses used in man for prophylaxis, diagnosis, therapy, or modification of physiologic functions.” — WHO Publication DEM/NC/84.153(E), June 1984.
Trigger Tool for Measuring AdverseDrug Events – Institute forHealthcare The Trigger Tool for Measuring Adverse Drug Events provides instructions for conducting a retrospective review of patient records using triggers to identify possible ADEs. This tool includes a list of known ADE triggers and instructions for collecting the data you need to measure the number of ADEs per 1,000 doses and the percentage of admissions with an ADE. The tool provides a process for accurately identifying ADEs and measuring the rate of ADEs over time.
Previous study on use ofComputerised Provider Order Entry(CPOE) system The study reviewed electronic health records for all the inpatients coming to 5 community hospitals for a 6 months duration (July 2010 – December 2010). Responses to 9 alerts/CDSS tools were studied, and these were displayed and prompted on computer screens when providers were putting in medication orders The study found that the CDSS system changed the physician behaviour & patient therapy 42% of the time when medication orders were placed. These alerts substantially decreased the medication error rate/adverse drug events (ADE’s) in the patients receiving care at these 5 hospitals.
Example taken from the study....