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Medical errors
Pharmacy seminar 2nd
Raghad almehmadi
Senior year
Pharmacy school
KAU
10/21/2016
1
10/21/2016
2
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3
Another study was conducted in 2013, in order to determine the pattern of
medical errors and litigations in saudi arabia.
The study analyzed 642 cases, mostly by MOH hospitals, it showed that:
• 20.4% of the cases was in the operating room,
• the emergency room by 18%,
• surgery and obstetric by 25% (highest),
• other medical specialties by 17 %,
It also showed that 46.5% of the cases involved patients aged 20-50 yrs.
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• A medical error is an adverse effect of care,
whether or not it is evident or harmful to the
patient. This might include an inaccurate or
incomplete diagnosis or treatment of a disease,
injury, syndrome, behavior, infection, etc.
• Failure to complete a planned action as
intended or the use of a wrong plan to achieve
an aim.
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Types of medical errors:
Medical
Errors
Medication
Surgical
Diagnostic
Infection
Blood
Transfusion
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Mistakes in the clinics:
Surgery departments
The “NEVER EVENTS”
 Wrong site, wrong procedure,
wrong patient
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Mishaps due to low level of care
 Nurses
“…A newspaper, published a statistic from the forensic
medicine department, said most of the mistakes were
committed by nurses, because the doctors were not given
correct information and there was no proper follow-up of
the cases…”
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9
Medication errors
 Rheumatoid arthritis Patient died after receiving an
overdose of methotrexate a 10-milligram Daily
Dose Of The Drug Rather Than The Intended 10-
milligram Weekly Dose.
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 One patient died because 20 units of insulin was
abbreviated as (20 U) but the "U" was mistaken for
a "zero”
 As a result, a dose of 200 units of insulin was
accidentally injected.
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Look-Alike, Sound-Alike Medication
Names.
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Do you remember what is the 5Rs rule?
5Rs
Right
medication
Right
patient
Right doseRight route
Right time
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So?
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15
Prevention:
“There is no single medical intervention, that
will save as many lives, as patients safety
improvement”
-D. berwick
Administrator of the Centers for Medicare
and Medicaid Services, USA.
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JCAHO
Bill
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18
ANA
The ANA supports policies that
eliminate manual patient lifting.
Safe patient-handling
techniques involve the use of
such equipment as full-body
slings, stand-assist lifts, lateral
transfer devices, and friction-
reducing devices.
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Advanced trauma life support(ATLS)
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Last word
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21
REFERENCES
 http://www.medscape.com/features/slideshow/med-
errors
 https://www.uthsc.edu/GME/psqi.php
 http://www.arabnews.com/saudi-arabia/news/830371
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC374865
4/
 https://psnet.ahrq.gov/primers/primer/3
 http://www.al-madina.com/node/614493
10/21/2016
22
THANK YOU FOR LISTENING
ANY QUISTION?
10/21/2016
23

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Medical errors

  • 1.  Medical errors Pharmacy seminar 2nd Raghad almehmadi Senior year Pharmacy school KAU 10/21/2016 1
  • 4. Another study was conducted in 2013, in order to determine the pattern of medical errors and litigations in saudi arabia. The study analyzed 642 cases, mostly by MOH hospitals, it showed that: • 20.4% of the cases was in the operating room, • the emergency room by 18%, • surgery and obstetric by 25% (highest), • other medical specialties by 17 %, It also showed that 46.5% of the cases involved patients aged 20-50 yrs. 10/21/2016 4
  • 6. • A medical error is an adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, etc. • Failure to complete a planned action as intended or the use of a wrong plan to achieve an aim. 10/21/2016 6
  • 7. Types of medical errors: Medical Errors Medication Surgical Diagnostic Infection Blood Transfusion 10/21/2016 7
  • 8. Mistakes in the clinics: Surgery departments The “NEVER EVENTS”  Wrong site, wrong procedure, wrong patient 10/21/2016 8
  • 9. Mishaps due to low level of care  Nurses “…A newspaper, published a statistic from the forensic medicine department, said most of the mistakes were committed by nurses, because the doctors were not given correct information and there was no proper follow-up of the cases…” 10/21/2016 9
  • 10. Medication errors  Rheumatoid arthritis Patient died after receiving an overdose of methotrexate a 10-milligram Daily Dose Of The Drug Rather Than The Intended 10- milligram Weekly Dose. 10/21/2016 10
  • 11.  One patient died because 20 units of insulin was abbreviated as (20 U) but the "U" was mistaken for a "zero”  As a result, a dose of 200 units of insulin was accidentally injected. 10/21/2016 11
  • 14. Do you remember what is the 5Rs rule? 5Rs Right medication Right patient Right doseRight route Right time 10/21/2016 14
  • 16. Prevention: “There is no single medical intervention, that will save as many lives, as patients safety improvement” -D. berwick Administrator of the Centers for Medicare and Medicaid Services, USA. 10/21/2016 16
  • 19. ANA The ANA supports policies that eliminate manual patient lifting. Safe patient-handling techniques involve the use of such equipment as full-body slings, stand-assist lifts, lateral transfer devices, and friction- reducing devices. 10/21/2016 19
  • 20. Advanced trauma life support(ATLS) 10/21/2016 20
  • 22. REFERENCES  http://www.medscape.com/features/slideshow/med- errors  https://www.uthsc.edu/GME/psqi.php  http://www.arabnews.com/saudi-arabia/news/830371  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC374865 4/  https://psnet.ahrq.gov/primers/primer/3  http://www.al-madina.com/node/614493 10/21/2016 22
  • 23. THANK YOU FOR LISTENING ANY QUISTION? 10/21/2016 23

Editor's Notes

  1. had a seizure and crashed his car into a tree, crushing both legs. Arteriography revealed that his right leg was salvageable but his left leg was not. Unfortunately, the x-ray technician mislabeled the films, mixing left for right, and the orthopedic surgeon first amputated Bill's right leg. Preventing wrong-site surgery became one of the main safety goals of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). Establishing protocols became an accreditation requirement for hospitals, ambulatory surgery centers, and office-based surgery sites.
  2. Lillian was 68 years old and weighed 250 lb when she underwent surgery to remove her gallbladder. The second day after surgery, she needed help to walk to the bathroom. Lillian's nurse, Millie, wasn't strong enough to support her and they both fell, breaking Millie's right arm and Lillian's left leg.
  3. In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a cornfield in Nebraska, sustaining serious injuries. His wife was killed, and 3 of their 4 children were critically injured. At the local hospital, the care that he and his children received was inadequate, even by standards in those days. "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed," Dr. Styner said