This document outlines a strategic plan to minimize medication errors in healthcare. It begins by defining medication errors and classifying their significance. It then discusses the extent of medication errors, finding they occur in 1 in every 19 hospital admissions. The document examines the many factors that contribute to errors, including poor communication, look-alike drug names, and busy work environments. It also presents approaches to reduce errors such as electronic medical records, barcoding medications, and computerized physician order entry, which can reduce serious medication errors by up to 81%. The goal of the plan is to understand, prevent, and minimize medication errors to improve patient safety.
Medication error- Etiology and strategic methods to reduce the incidence of M...Dr. Jibin Mathew
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer
Medication error- Etiology and strategic methods to reduce the incidence of M...Dr. Jibin Mathew
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer
Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.
Clinical pharmacy may be defined as the science and practice of rationale use of
medications, where the pharmacists are more oriented towards the patient care
rationalizing medication therapy promoting health , wellness of people.
It is the modern and extended field of pharmacy.
“ The discipline that embodies the application and development (by pharmacist) of
scientific principles of pharmacology, toxicology, therapeutics, and clinical pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied
sciences for the care of patients”.
Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.
Clinical pharmacy may be defined as the science and practice of rationale use of
medications, where the pharmacists are more oriented towards the patient care
rationalizing medication therapy promoting health , wellness of people.
It is the modern and extended field of pharmacy.
“ The discipline that embodies the application and development (by pharmacist) of
scientific principles of pharmacology, toxicology, therapeutics, and clinical pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied
sciences for the care of patients”.
More people die annually from medication errors than from workplace injuries. An error in the prescribing, dispensing, administration of a drug irrespective of whether such errors lead to adverse consequences or not. In India, Medication Error is just a TERM and its significance is undervalued and remains unreported. Reported incidence of this iatrogenic disease related to medication error- tip of the iceberg. medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents
Medication errors are described under prescription errors, transcription errors, administration errors. Based on the causes of errors the NCC MERP Index is formulated to categorize medication errors from Category A- I. Appropriate monitoring, good team communication, knowledgeable staff, RCA and policy on check of medication errors can reduce its incidence and make patient more safe.
ADVERSE DRUG REACTION | PHARMACY PRACTICE | PDF | SHIVAM DUBEY B PHARMA | PHA...MrHotmaster1
PHARMACY PRACTICE
SHIVAM DUBEY
BPYN1PY18041
ADVERSE DRUG REACTION Abstract
We define an adverse drug reaction as "an appreciably harmful or
unpleasant reaction
Presentation by Avella Specialty Pharmacy & mScripts at Armada 2015 on improving medication adherence through mobile app technology. Learn about how Avella meets the challenges of medication non-adherence: http://www.avella.com/medication-adherence
Medication therapy is becoming increasingly more complex as new drugs are developed and more therapeutic targets are elucidated. In addition, polypharmacy (≥5 scheduled medications) has become exceedingly common in geriatric patients and in patients with chronic disease states. As the complexity of drug therapy and the number of medications increase, patients are at a high risk for medication errors and adverse drug events (ADEs), or injuries resulting from medication. The type of adverse events may be associated with professional practices, healthcare products, procedures, and systems including prescription, communication through instructions, drug labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring, and use. Classification and evaluation of medication errors according to their importance may constitute an important factor for process improvement in order to render the administration of medicines as safe as possible. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Technology has grown to be a constituent part of medicine these days. A few advantages that technology can supply are categorized as follows: the assisting of communication between clinicians; enhancing medication safety; decreasing potential medical errors and adverse events; rising access to medical information and encouraging patient-centered healthcare. The aim of this article is to provide a compendious literature review regarding Medication errors
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
3. Define medication errors and classify their
significance
Understand the extent of medication errors
and their impact on patient care
Discuss the many factors that contribute to
errors and the impulse to “place blame” on
healthcare workers
Examine approaches to minimize the risk of
medication errors
4. "A medication error is any preventable event that
may cause or lead to inappropriate medication use
or patient harm while the medication is in the
control of the health care professional, patient, or
consumer. Such events may be related to:
National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at
http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.
• professional practice
• health care products
• procedures and systems
• product labeling, packaging,
and nomenclature
• dispensing
• distribution
• administration
• education
• monitoring
5. Medication Errors in 1,116 Hospitals
Medication Error (Overall)
430,586
5.07% (of admission)
1 error every 22.7 hr
1 every 19.7 admission
6. found 616 medication errors (5.7%),
115 potential ADEs (1.1%), and 26 ADEs
(0.24%). Of the 26 ADEs, 5 (19%) were
preventable.
Most potential ADEs occurred at the stage of
drug ordering (79%)
The rate of potential ADEs was significantly
higher in neonates in the neonatal intensive
care unit.
Ref: JAMA. 2001;285(16):2114-2120. doi:10.1001/jama.285.16.2114
Reviewed 10 778 medication orders
8. Kohn et al. Committee on quality health care in America. IOM. Academy Press. 1999.
Extra Extra
Airlines expect 1-2 jets to
crash daily
Over 1000 deaths expected
weekly
=
44,000 – 98,000
deaths annually
due to
medical errors
9. A Comparison of Risks
Risk (per flight) of dying in a commercial
airline accident
1 in 8 million*
Risk (per hospital admission)
of dying from a medical error >1 in 1,000
*1 in 2 million from 1967-1976
11. NCC MERP. accessed Jan 2012. www.nccmerp.org
Classifying medication errors
A circumstances exist for potential errors to occur
B an error occurred but did not reach the patient
C error reached the patient but did not cause harm
D patient monitoring required to determine lack of harm
E error caused temporary harm and some intervention
F temporary harm with initial or prolonged hospitalization
G error resulted in permanent patient harm
H error required intervention to sustain the patient’s life
I error contributed to the patient’s death
15. Some reasons errors occur
• poor communications within healthcare team
• verbal orders
• poor handwriting
• improper drug selection
• missing medication
• incorrect scheduling
• look alike / sound alike drugs
• polypharmacy
• availability of floor stock (no second check)
• drug interactions
• hectic work environment
• lack of computer decision support
16. Calculation errors
Improper use of zeros & decimal points
Inappropriate use of abbreviations
Careless prescribing
Illegible handwriting
Missing information
Drug product characteristics
Compounding /drug preparation errors
Prescription labeling
Work environment & personnel issues
Deficiencies in medication use systems
17. Medication Errors, Who Makes Them?
Physician Pharmacist Nurse Patient
Any
member of
the health
care team
20. 0
20
40
60
80
100
120
140
160
180
No Diagnosis Prohibited
Abbr
No Gen Name Prescription
Previlage
No.file No. weak
strenght
No Diagnosis
Prohibited Abbr
No Gen Name
Prescription Previlage
No.file No.
weak strenght
MOST COMMON ERROR TOTAL NO. OF ERROR QUARTER
No Diagnosis
148
Prohibited Abbr 80
No Gen Name
168
Prescription Previlage 57
No.file No. 98
Weak Strength 57
21.
22.
23.
24.
25. An anticonvulsant
approved in Canada and the US
since2005 to treat neuropathic pain
approved by the European
Commission in 2006 to treat
generalized anxiety disorder.
The maximum dose of pregabalin
depends on its indication but should
not exceed 600 mg/day.
26. Clinical studies including 5500 patients
showed that euphoric effects were reported
more frequently in pregabalin groups versus
placebo (4% vs. 1%, respectively).
A clinical abuse liability study found that
pregabalin had a potential for euphorigenic
activity in susceptible populations.
Therefore scheduled by the US Drug
Enforcement Administration under the
Controlled Substances Act as a Schedule V
drug, indicating that
it had abuse potential.
27. Emerg Med J 2013;30:874 doi:10.1136/emermed-2013-203113.20
•Abstracts
Lyrica Nights–recreational Pregabalin
Abuse In An Urban Emergency Dept
Author Affiliations
1.Emergency Department, Royal Victoria Hospital, Belfast, United
Kingdom
"Pregabalin Abuse, Dependence, and Withdrawal: A
Case Report." The American Journal of Psychiatry,
167(7), p. 869
29. Reconciliation: A process of identifying the
most accurate list of all medications a
patient is taking—including name, dosage,
frequency, and route.
Requires comparing the patient’s list of
current medications against the physician’s
admission, transfer, and/or discharge
orders
Needs even for OPD patients by MOH
http://www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D-91B5-
B836D23A6F1D/0/CampaignOverview101105.ppt#358,9,Prevent Adverse Drug Events by Implementing Medication
Reconciliation
32. Factors:
health status of patients
magnitude of overdose
damage as result of omission
Financial Implications
prolong hospital stays & increase health care
expenses
estimated to cost billions of dollars annually
additional medical management
33. Sources of Error
• Prescribing error - selecting the wrong or
inappropriate drug/dose/formulation/duration etc
• Communicating those instructions
• Supply error - timely; wrong drug, dose, route;
expired medicines, labelling.
• Administration error - timing; wrong route; wrong
rate/technique.
• Lack of user education - actions to take.
37. “AZT” for zidovudine (Retrovir)
could be azathioprine (Imuran)
“U” HAS been mistaken for “zero”(o)
10 U insulin order & patient received 100 insulin
units
“QD” has been read as “QID” or “OD”
DO NOT USE Lists
The Joint Commission
Institute for Safe Medication Practices (ISMP
38.
39.
40. Decimal point errors cause significant
consequences
Decimal point errors occur
result of miscalculation
when writing orders or instructions
result of artifact on faxed order
Always write leading zero in front of
number < 1
Never write trailing zeros
41.
42.
43. e-Prescribing Systems:
Reduced medication errors by 85%
Net cost savings of $403,000 in ambulatory care settings22,23
Bar Code Electronic Medication Administration System (eMAR)
Technology:
51% reduction in medication errors
Annual savings of $2.2 million in a large academic hospital24,25
• Computerized Physician Order Entry
(CPOE):
– Reduced serious medication errors by 81%26
Notes
22. Kaushal, R., Kern, L.M., Barrón, Y., et al. (2010). Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med, 25(6), 530-536.
23. Weingart, S.N., Simchowitz, B., Padolsky, H., et al. (2009). An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and
cost in ambulatory care. Arch Intern Med, 169(16), 1465-1473.
24. Poon, E.G., Keohane, C.A., Yoon, C.S., et al. (2010). Effect of bar-code technology on the safety of medication administration. N Engl J Med, 362(18),1698-1707.
25. Maviglia, S.M., Yoo, J.Y., Franz, C., et al. (2007). Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Intern Med, 167(8), 788-794.
26. Bates, D.W., Teich, J.M., Lee, J., et al. (1999). The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc, 6(4), 313-321.
44. Clinical Effectiveness of Safe Practices
Intervention Results
Physician computer order entry 81% reduction of medication
errors
Pharmacist rounding with team 66% reduction of preventable
adverse drug events; 78%
reduction of preventable adverse
drug events
Rapid response teams Cardiac arrests decreased by 15%
Team training in labor and delivery 50% reduction in adverse
outcomes in preterm deliveries
Reconciling medication practices
upon hospital discharge
90% reduction in medication
errors
45. Failure to include concentration in
prescription can result in wrong dose being
dispensed
amoxicillin suspension 1/2 tsp (2.5 mL) TID
Concentration?
“1 amp,” “1 vial,” “1 cap” unclear
multiple strengths, doses, or vial sizes
Order for one “vial” of magnesium sulfate?
2 mL vial (8 mEq)
20 mL vial (16 mEq)
10 mL vial of 50% concentration (40 mEq)
46. Handwriting of physicians is subject of jokes
no laughing matter
Unclear orders should be clarified
Use standardized, preprinted order forms
Computer generated & typewritten labels
Use of upper- and lowercase lettering
(TALLman)
47. Lack of medical information about patient
may cause error
age
weight
allergies
diagnosis
indication & severity of condition
48. Error is inevitable due to “our” limitations:
- limited memory capacity
- limited mental processing capacity
- negative effects of fatigue other stressors
We all make errors all the time
Patients suffer adverse events much more
often than previously realised
Errors often NOT immediately observed
49. Human beings will always make
errors
Errors are common in medicine,
killing tens of thousands
Naming, blaming and shaming
have no remedial value