Medicinal cannabis has become the new standard

1. Drug and Poison Information
CLNI 522 (2021 -22)
Lecture 5 :
Medication Safety Practice in Hospital (part 1)
University of Hail

2. Case
• A 34-year-old xyz expectant mother died at a private
hospital after her four-month-old foetus and uterus were
surgically removed.
• Doctors claimed the baby had turned in her
abdomen. After the check-up, doctors said xyz was four
months pregnant and the baby had turned, which was not
normal. Her foetus was removed surgically and coagulant
was administered. Still bleeding was not under control and
second surgery was done to remove uterus.
• After the surgery, Dr told relative that the bleeding has
stopped and would be normal in 24 hours. She was then
shifted to the ICU. Still bleeding continued. Kidney tests
revealed that her kidney failed and had UTI. But when xyz
developed severe breathing difficulties, they re-admitted
her. Then she died.
•
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3. • What is the possible reasons for death ?
• What is the error here?
• Which type of error ?
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Objectives
• Introduction to medical error .
• Definition of Medication Error (ME) and
Adverse drug event
• Causes of error .
• Contributing factors .
• Prescribing Error
• Dispensing Error
• Administration Error
• Look-Alike & Sound-Alike
• Action Plan

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Introduction
• Medical Error…..
“The very term sounds ominous.
And well it should be……
When you enter a hospital or a nursing home or
go to a doctor’s office……
you don’t always expect to be cured…
but…….
you certainly don’t expect to be hurt.”
Lucian Leape, M.D.

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The Dimensions of Quality

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