Medication error


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Medication error

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