The document discusses medication errors, including common types, causes, and strategies for prevention. It notes that medication errors are a serious issue, causing up to 98,000 deaths per year. Errors can occur at any step in the medication process and are often due to human factors like poor communication or illegible handwriting, as well as system factors like confusing drug names. Strategies to reduce errors include using clear verbal order protocols, limiting dangerous abbreviations, implementing computerized physician order entry and barcoding, and having a just culture approach that supports healthcare workers involved in errors.
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
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.
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.
Medication Errors A Serious Topic Left Behind Leslie Richard
Medication Error is the third most common desiese leading to death . A serious topic for nurses and doctor's which was left behind . What to do in case of High Alert .
Polypharmacy and Rational Prescribing in Elderly Patients.pptxAhmed Mshari
Polypharmacy is typically defined as the prescription of five or more medications.
It also refers to the prescription of medications that do not have a specific current indication, that duplicate other medications, or that are known to be ineffective for the condition being treated.
In other words, polypharmacy is the use of multiple medications that are unnecessary and have the potential to do more harm than good.
Unnecesary Medication Use in Long Term Care FacilitesDebbie Ohl
Meds are a key component in the clinical process.
The guidelines are intended to insure medication use is of value and necessary. T
Significant emphasis is placed on preventing and recognizing adverse drug reactions ASAP.
Consequently, surveyors will expect to see:
Rationale for use, Parameters for monitoring
Prompt recognition and evaluation of new onset problems and conditions worsening
Consideration for dose reduction and discontinuance as appropriate.
Medication Error are the most preventable events and Clinical Pharmacists can play a vital role in preventing them. in this presentation i have tried to provide maximum information regarding medication error in minimum slides.
Current Situation of Medical ErrorsPrepared byAsOllieShoresna
Current Situation of Medical Errors
Prepared by Asma Alshammari Alhanoof Alaniz Teflah Ali Mai Alrweeli Munyfaa Aldhafeeri Norah Almoteri
Introduction
Health care processes are increasingly being implicated in causing harm to patients. Medical errors and adverse events are primarily responsible for this harm. These errors, which may occur at every level of the custom are both common and diverse in nature.
Medical errors can occur anywhere in the health care system in hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes and can have serious consequences. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports.
Medical errors represent a serious public health problem and pose a threat to patient safety. As health care institutions establish “error” as a clinical and research priority, the answer to perhaps the most fundamental question remains elusive: What is a medical error? To reduce medical error, accurate measurements of its incidence, based on clear and consistent definitions, are essential prerequisites for effective action.
Despite a growing body of literature and research on error in medicine, few studies have defined or measured “medical error” directly. Instead, researchers have adopted surrogate measures of error that largely depend on adverse patient outcomes or injury (i.e., are outcome-dependent).
A lack of standardized nomenclature and the use of multiple and overlapping definitions of medical error have hindered data synthesis, analysis, collaborative work and evaluation of the impact of changes in health care delivery.
Medical error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim”. A medical error is a threat to patient safety and has a negative effect on health as well.
Definition of Medical Error
Medical error the term “error” has been variously defined. The Oxford Dictionary of Current English (1998) defines it as “mistake” or the condition of being morally “wrong”. Error has also been defined in a wider context as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (Reason, 1990). Although the definition of “error” has its origins in behavioral psychology, the term is appropriate for medical usage. Using Reason's definition, IOM has tried to separate medical error into two parts (Kohn et al., 2000): the first half of the definition constitutes “error of execution” and the latter half, “error of planning.” In this context, two other related terms, “adverse event” and “patient safety.” Bates et al. (1997) defined adverse events as injuries that result from medical management, rather than from the underlying disease. Patient safety, as defined by IOM, is freedom from accidental injury (Kohn et al., 2000). All three terms, “medical error,” “adverse event,” and “patient safety” complement one another.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- GENE THERAPY
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- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
50. BPOC Bedside Device Wireless Laptop computer with a touch screen and bar code scanner
51. Barcode Technology Nurse barcode scans name tag Nurse barcode scans patient identification bracelet Patient MAR appears on bedside laptop Scheduled and prn meds are scanned Warnings/alerts are issued when indicated
52.
53.
54.
55. ADE, ADR, & Medication Errors Adverse Drug Events
56.
57. Consequences of ADEs Anaphylaxis – penicillin Deafness – gentimycin Pseudo. colitis –clindamycin Thrombocytopenia –heparin GI upset –erythromycin Urticaria – phenytoin Death $$$$ Permanent disability $$$$ Threat to Life $$$ Hospitalization $$$ ER visit $$$ Inconvenience $
This chart shows the breakdown of medication error types for the 594 reports in which a patient died. Improper dose was the most common type, with a majority being overdoses (36.4%) Wrong drug (inadvertant administration of one drug product for another, e.g. potassium chloride injection instead of sodium chloride) Wrong route was the other major type of error (intrathecal instead of IV most common) Wrong patient fairly uncommon Other is comprised of wrong technique/rate/strength/dosage form/time, as well as monitoring and deteriorated drug errors (aggregate of many small things)
In order to reduce the number of medication errors occurring, we need to recognize the behaviors that are causing the errors to occur. By far, human factors are the biggest cause. Includes: Performance deficits (gave drug IV instead of IM) Knowledge deficits (reasonable practice standards of education/CE) Dose miscalculations Preparation errors (wrong diluent, drug, active ingredient, or quantity) Incorrect selection of drug from computer/transcription errors Communication Order misinterpretation Oral/written miscommunication Name confusion Sound alike/look alike
Something we’re all very familiar with (common question for RPh from techs “What does this say?) An’t go ONE day w/out saying this-preprnted/electronic froms rxs Can be tricky sometimes our assumptions are not correct Absolutely critical to double check on handwriting problems! Combinations of bad handwriting and similar drug names create perfect conditions for errors Example report of fatal bleeding in a patient prescribed Cogentin 0.5mg and given Coumadin 5 mg
Errors of communication are an all too common cause of medication errors, particularly wrong drug and dose/frequency errors. Can be significantly reduced through double checks and following best practices for taking verbal orders and writing prescriptions
This hospital order is difficult to interpret. Drug name looks like Plendil (wrong dose/frequency), or Zestril (right dose, wrong frequency), but may be something else based on the dose/directions.
This is an order for HCTZ 50 mg PO daily; however, the lack of spacing between the drug name and strength could be misinterpreted as 250 mg of HCTZ per day
Abbreviation misinterpretation is a frequent cause of mix-ups, and the ISMP/FDA are leading a campaign to eliminate the use of certain error-prone abbreviations Recommended that these abbreviations be written out QD/QOD/QID may be mistaken for one another if handwriting is not clear simply write out direction Do not abbreviate drug names (e.g. MS for “morphine sulfate” may be mistaken for magnesium sulfate) Eye/ear directions may look similar if handwriting is poor, leading to route of administration errors Source: http://www.nccmerp.org/dangerousAbbrev.html
An order for regular insulin. As written, it could be interpreted as 6 U (six units) now, or as 60 units now. A 60 unit dose is improbable, but may be overlooked or not questioned, which could easily cause a patient’s glucose to bottom out
Those of us that work on order forms know how prevalent these abbreviations still are Units of weights and measures also leave plenty of room for error U may be mistaken for a 0 or 6 IU may be mistaken for IV, leading to fatal IV administration errors µg may be misread as milligram instead of microgram, a thousandfold dose error Apothecary units are often unfamiliar to practitioners Use of fractions of a grain (e.g. 1/100 grain) can lead to fraction errors or conversions to metric Use of symbols for teaspoon/tablespoon/ounce can be confusing
Decimal errors are of particular importance because an error in a decimal can result in a ten or more-fold dose error! The problem with decimals is that they always leave a space for error if missed. Avoid whenever possible. Always place a zero in FRONT of a decimal to avoid misinterpretation (Risperdal .5 may be read as “5 mg”, a ten fold overdose) Avoid trailing zeros whenever possible
Seeing it in actual writing makes it easier to recall how easily decimal errors can occur. Simply missing the decimal would expose a patient to a ten-fold overdose of colchicine or levothyroxine, both of which would have serious consequences
A number of drugs have names that look similar enough to cause confusion These names may be misread when in a hurry or not paying close attention to work Compounding the problem is the fact that some of these drugs have similar strengths and indications These are just a few examples. A complete list is available from the ISMPs website Not JUST names but PACKAGING too
Just as look alike drugs can lead to errors in prescription reading and dispensing, sound alike drugs are a pitfall of verbal orders for medication
Verbal prescription orders add an extra risk of error in several ways Communication issues foreign/local accents or dialects may be misunderstood Background noise in the pharmacy/MD office, as well as interruptions Unfamiliarity with the drug name, terminology for directions may generate an error Despite convenience of verbal orders, they do add an additional step for an error to be made, a risk which must be mitigated
So what behaviors can we change to reduce the number of verbal order errors that occur? Having a set read-back procedure is a easy way to immediately double check what was just ordered Read back patient name, DOB, drug name, strength, dose, frequency, quantity Double checking protects everyone patients from drug errors, and health care professionals/hospitals from liability resulting from errors
Study published in 2010 NEJM this year found that the use of bar coding technology coupled with electronic medication administration records (eMARs) significantly reduced the rate of error in the hospital setting Technology cross-checks bar codes on a patient’s wrist with the drug about to be administered to ensure the correct patient, drug, strength/dose, and time.
This diagram gives a visual of the relationship between ADE, adverse drug reactions, and medication errors for perspective. The intent is to illustrate several points: Not all MEs result in ADE, and fewer result in ADR (only about 1% result in ADE) Approximately 25% of ADEs are caused by medication errors, and are often serious in nature That the small percent of ADEs resulting from errors costs the patients and the healthcare system such an enormous amount drives the need to reduce errors wherever possible Source: Nebecker et al. Clarifying Adverse Drug Events. Ann Intern Med 2004; 140: 795-801.
This slide is intended to visually highlight the impact of ADEs across the spectrum of severity Minor ADEs may cause simple inconveniences like GI upset or drowsiness Moderate ADEs may require medical attention or hospitalization, leading to greater financial burdens Severe ADEs lead to serious consequences, which in addition to creating a financial burden for patients, also tend to greatly impact a patients quality of life, particularly if full recovery is impossible (e.g. aminoglycoside hearing loss)
Process at Shore. Helps ID problems
These are some non-punitive approaches to error reduction By fostering an environment where practitioners do not need to fear being publicly or professionally “crucified”, we can encourage the reporting of errors and provide constructive feedback on how to make changes from the blunt end. Community/media education about error prevention efforts is important People need to know the healthcare field is made of other people who genuinely care about their safety The media tends to sensationalize medication errors, so making knowledge of error prevention efforts public may be a good way to mitigate this
It is important to focus on the human factors involved in medication errors due to the inherent limitations of the human brain Past research has shown us that humans can store at the most around 7 items in short term memory, which in reality may be a generous limit Number is limited in practice due to other things pulling our attention away This has happened to all of us focused on multiple things and end up forgetting something important Humans have a limited capacity to remember things, as well as to observe events going on around us We aren’t very good at estimating probability, possibly due to other factors that influence our predictions of events (e.g. whether we want an event to happen or not or whether we have all the details)
So how do we reduce human error in the health care system? We use computers to perform tasks that are tedious, or which may involve significant human error. Computers have their own limitations, chief of which is that they are only as good as the person using them computers don’t make mistakes, the people using them do Computers are unable (right now) to show common sense or true clinical judgement They can only generate results based on set parameters (for example, listing all possible drug interactions for a given drug pair, rather than decided which ones to question and which ones to let go)
Simply double checking key information while entering a script can prevent errors
Coach your staff into the habit of multi-checking everything Checks of
Route of administration errors carry a greater potential to cause fatal medication errors due to inadvertent IV/IT administration Constant vigilance and questioning is required to prevent Labeling of products not intended for a particular route of administration is critical Examples Nonsterile/non-pH balanced ear preps used in the eye can cause irritation and other problems FDA reports of deaths linked to accidental administration of nimodipine oral capsules intravenously (nimodipine is used for control of vasospasm s/p cerebral hemorrhage) Liquid in capsule withdrawn using IV syringe and 18 gauge needle for use with nasogastric tube syringe not labeled and later given IV push, leading to death Reports of deaths when vinca alkaloids used for chemotherapy were given intrathecally instead of IV
Find a way to differentiate products that look similar Often an issue with a generic brand that uses identical packaging for many drugs (Mylan in particular) “ Tall Boy” lettering style – highlights portions of drug name that are dissimilar Be creative in coming up with a way to effectively differentiate between similar drug products. Shelf separators should be a part of any system, as they prevent drugs/strengths from getting mixed together