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This document discusses medical errors and medication errors. It defines medical errors as failures of planned actions or use of wrong plans that lead to patient harm. Medication errors are defined as preventable events involving medication use that may cause patient harm. The document notes that medical errors are the eighth leading cause of death in Pakistan, with around 7,000 deaths per year due to medication errors alone. Causes of medication errors discussed include errors of omission, errors of commission, communication failures, and failure to follow policies. The Swiss cheese model of layered defenses is presented as a way to understand how latent errors in the system can combine to cause patient harm. Types of medication errors like prescribing, dispensing, and administration errors are explained. Steps
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medical error
This document discusses medical errors and medication errors. It defines medical errors as failures of planned actions or use of wrong plans that lead to unintended outcomes like adverse drug events. Medication errors are defined as preventable events involving medication use that may cause harm. The document notes that medical errors are the eighth leading cause of death in Pakistan, with around 7,000 deaths annually due to medication errors. Causes of medication errors discussed include omissions, commissions, communication failures, and environmental factors. The Swiss cheese model is presented as a way to understand how latent errors in the system can combine to cause patient harm when defenses are missed. Types of medication errors and steps to prevent errors are also outlined.
Medication error
Medication errors are preventable causes of patient harm and can occur at any stage of the medication process from prescribing to administration. There are many types of medication errors including omission errors, unauthorized drug errors, wrong dose errors, and wrong route errors. Factors that contribute to medication errors include illegible handwriting, confusion over drug names, lack of knowledge about drugs, and interruptions during medication administration. Some steps to prevent medication errors are following the rights of medication administration, double checking all calculations, avoiding distractions, and questioning any unclear or unusual orders.
Med errors apa
This document discusses medication errors, including their scope and causes. It notes that medication errors are a major problem, causing many preventable deaths each year and billions in costs. Common causes of errors include look-alike drug names and packaging, multiple drug concentrations, labeling issues, and time constraints on nurses. High-risk drugs and IV medications are particularly prone to errors. Errors can involve wrong drugs, doses, preparations or contamination. The document outlines various technologies and practices that can help reduce errors, such as electronic prescribing, bar coding, and computerized physician order entry.
Medical errors....
Medical errors represent a serious public health problem and occur frequently in various healthcare settings. They can involve medicines, surgery, diagnosis, equipment, or lab reports. Studies estimate medical errors may be the third leading cause of death in the US, resulting in between 200,000 to 400,000 deaths per year. Many common types of errors like misdiagnosis, unnecessary treatment, medication mistakes, and uncoordinated care have been reduced through standardized protocols and safety practices, but medical errors still frequently harm and kill patients.
Medical errors
The document summarizes a study analyzing 642 medical error cases in Saudi Arabia. The study found that 20.4% of errors occurred in operating rooms, while 18% were in emergency rooms and 25% in surgery and obstetrics. Nearly half (46.5%) of cases involved patients aged 20-50 years. Common types of medical errors discussed include medication errors, surgical mistakes, and diagnostic errors. Specific examples are provided like a patient receiving an overdose of methotrexate which resulted in death. The presentation emphasizes the importance of patient safety and prevention of errors through techniques like using the 5Rs rule of administering the right medication to the right patient in the right dose via the right route at the right time.
HOW TO MINIMIZE MEDICATION ERROR
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
Medication errors are a significant problem in healthcare that can harm patients. They occur commonly at various stages of the medication process including prescribing, transcribing, preparing, dispensing, and administering medications. Several studies over decades have found high rates of medication errors and preventable adverse drug events in hospitals. James Reason developed a widely used model for classifying errors as either active failures by frontline staff or latent failures due to upstream organizational or management issues. Understanding the causes of errors through models like Reason's can help pharmacists and other healthcare providers develop effective strategies to improve medication safety.
Prescription Patterns
When a psychiatric patient is diagnosed, the practitioner selects a medication therapy from a variety of therapeutic approaches and according to the severity and condition of a patient; through peer evaluation. This requires the writing of a prescription. Prescribing accounts for a large proportion of errors [1]: Medication errors, problems related to strength and frequency of medication, quantity per dose, instructions for use, total quantity to be dispensed, dosage form etc; if absent, can cause great deal of patients’ harm. Medicines are a key component of healthcare and errors relating to medication, may impact on patient’s safety [1-4].
Human errors can be understood through a lot of suggested models and frameworks but the findings vary from country to country [5,6]. Prescribing errors are harmful to the patients and in worst cases they may lead to fatality. To avoid errors in prescriptions and its amelioration at the time of writing; is the easiest way of prevention of prescription errors [6-10]
Theories of human error states that, “a series of planned actions may fail to achieve their desired outcome because the plan itself was inadequate or because the actions did not go as planned. The definition reflects this distinction, including failures both in the prescribing decision and the prescription writing process” [5]. In 2005, Department of Health in the United Kingdom planned to reduce prescribing errors by 40% [10]. Such initiatives are also required in a developing country like Pakistan. Apparently, psychiatrists know a little about prescribing errors. Irrational drug therapy can cause patient’s harm by exacerbation or prolongation of illness, distress and higher costs [8] in some cases. Irrational prescribing is a global problem and may also be regarded as "pathological" prescribing [9].
All prescriptions must include the name, address, specialty and signature of the prescriber as well as the name, sex, and age of the patient and the strength, quantity, dose, frequency, dosage form and instructions for use of the medication [11–15]. The dispensing system of Pakistan is different than some other countries. The medication is available in already packed in containers etc by the pharmaceutical industries, to be dispensed. There is no option of refill instructions to the pharmacist etc. Adherence by the physician to good quality prescribing will minimize errors and ultimately improve patient’s care. Prescribing errors can occur as a result of errors in haste, poor concentration to the patient or attendant (in case the patient is unable to deliver the correct information), decision-making or the prescription-writing process. Incorrect prescribing habits are common unfortunately [16-20].
The purpose of this study was to investigate drug prescriptions of Psychiatry for the essential elements of prescriptions mentioned above, and to study the prescribing trends in psychiatric practice in Peshawar area, Pakistan.
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medical error
This document discusses medical errors and medication errors. It defines medical errors as failures of planned actions or use of wrong plans that lead to unintended outcomes like adverse drug events. Medication errors are defined as preventable events involving medication use that may cause harm. The document notes that medical errors are the eighth leading cause of death in Pakistan, with around 7,000 deaths annually due to medication errors. Causes of medication errors discussed include omissions, commissions, communication failures, and environmental factors. The Swiss cheese model is presented as a way to understand how latent errors in the system can combine to cause patient harm when defenses are missed. Types of medication errors and steps to prevent errors are also outlined.
Medication error
Medication errors are preventable causes of patient harm and can occur at any stage of the medication process from prescribing to administration. There are many types of medication errors including omission errors, unauthorized drug errors, wrong dose errors, and wrong route errors. Factors that contribute to medication errors include illegible handwriting, confusion over drug names, lack of knowledge about drugs, and interruptions during medication administration. Some steps to prevent medication errors are following the rights of medication administration, double checking all calculations, avoiding distractions, and questioning any unclear or unusual orders.
Med errors apa
This document discusses medication errors, including their scope and causes. It notes that medication errors are a major problem, causing many preventable deaths each year and billions in costs. Common causes of errors include look-alike drug names and packaging, multiple drug concentrations, labeling issues, and time constraints on nurses. High-risk drugs and IV medications are particularly prone to errors. Errors can involve wrong drugs, doses, preparations or contamination. The document outlines various technologies and practices that can help reduce errors, such as electronic prescribing, bar coding, and computerized physician order entry.
Medical errors....
Medical errors represent a serious public health problem and occur frequently in various healthcare settings. They can involve medicines, surgery, diagnosis, equipment, or lab reports. Studies estimate medical errors may be the third leading cause of death in the US, resulting in between 200,000 to 400,000 deaths per year. Many common types of errors like misdiagnosis, unnecessary treatment, medication mistakes, and uncoordinated care have been reduced through standardized protocols and safety practices, but medical errors still frequently harm and kill patients.
Medical errors
The document summarizes a study analyzing 642 medical error cases in Saudi Arabia. The study found that 20.4% of errors occurred in operating rooms, while 18% were in emergency rooms and 25% in surgery and obstetrics. Nearly half (46.5%) of cases involved patients aged 20-50 years. Common types of medical errors discussed include medication errors, surgical mistakes, and diagnostic errors. Specific examples are provided like a patient receiving an overdose of methotrexate which resulted in death. The presentation emphasizes the importance of patient safety and prevention of errors through techniques like using the 5Rs rule of administering the right medication to the right patient in the right dose via the right route at the right time.
HOW TO MINIMIZE MEDICATION ERROR
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
Medication errors are a significant problem in healthcare that can harm patients. They occur commonly at various stages of the medication process including prescribing, transcribing, preparing, dispensing, and administering medications. Several studies over decades have found high rates of medication errors and preventable adverse drug events in hospitals. James Reason developed a widely used model for classifying errors as either active failures by frontline staff or latent failures due to upstream organizational or management issues. Understanding the causes of errors through models like Reason's can help pharmacists and other healthcare providers develop effective strategies to improve medication safety.
Prescription Patterns
When a psychiatric patient is diagnosed, the practitioner selects a medication therapy from a variety of therapeutic approaches and according to the severity and condition of a patient; through peer evaluation. This requires the writing of a prescription. Prescribing accounts for a large proportion of errors [1]: Medication errors, problems related to strength and frequency of medication, quantity per dose, instructions for use, total quantity to be dispensed, dosage form etc; if absent, can cause great deal of patients’ harm. Medicines are a key component of healthcare and errors relating to medication, may impact on patient’s safety [1-4].
Human errors can be understood through a lot of suggested models and frameworks but the findings vary from country to country [5,6]. Prescribing errors are harmful to the patients and in worst cases they may lead to fatality. To avoid errors in prescriptions and its amelioration at the time of writing; is the easiest way of prevention of prescription errors [6-10]
Theories of human error states that, “a series of planned actions may fail to achieve their desired outcome because the plan itself was inadequate or because the actions did not go as planned. The definition reflects this distinction, including failures both in the prescribing decision and the prescription writing process” [5]. In 2005, Department of Health in the United Kingdom planned to reduce prescribing errors by 40% [10]. Such initiatives are also required in a developing country like Pakistan. Apparently, psychiatrists know a little about prescribing errors. Irrational drug therapy can cause patient’s harm by exacerbation or prolongation of illness, distress and higher costs [8] in some cases. Irrational prescribing is a global problem and may also be regarded as "pathological" prescribing [9].
All prescriptions must include the name, address, specialty and signature of the prescriber as well as the name, sex, and age of the patient and the strength, quantity, dose, frequency, dosage form and instructions for use of the medication [11–15]. The dispensing system of Pakistan is different than some other countries. The medication is available in already packed in containers etc by the pharmaceutical industries, to be dispensed. There is no option of refill instructions to the pharmacist etc. Adherence by the physician to good quality prescribing will minimize errors and ultimately improve patient’s care. Prescribing errors can occur as a result of errors in haste, poor concentration to the patient or attendant (in case the patient is unable to deliver the correct information), decision-making or the prescription-writing process. Incorrect prescribing habits are common unfortunately [16-20].
The purpose of this study was to investigate drug prescriptions of Psychiatry for the essential elements of prescriptions mentioned above, and to study the prescribing trends in psychiatric practice in Peshawar area, Pakistan.
What is a ‘medication error’
The document discusses medication errors, which are preventable failures in the treatment process that can harm patients. It defines medication errors and classifies them by cause, stage of occurrence, and severity of harm. Prescribing errors are the most common, followed by administration and dispensing errors. Technologies like computerized prescribing and barcoding can reduce errors but implementing them faces challenges. Improving handwritten prescription quality, such as using standard formats and avoiding ambiguous abbreviations, also aims to reduce errors. The conclusion emphasizes that both technological solutions and improving manual processes are needed to enhance patient safety by reducing medication errors.
Polypharmacy in elderly patients:an intervention study in therapeutic management
Oral presentation, 21° WONCA World Conference of Family Doctors, 3 november 2016, Rio de Janeiro, Brazil
Medication errors: Causes, Assessment, Evaluation and Prevention
This gives information about what are medication errors, causes, Levels and Approaches to evaluate and Minimize them
Medical errors
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
Medication errors
Medication errors can occur at various stages including prescribing, dispensing, and administration. They are caused by factors like illegible handwriting, confusion between drug names, interruptions during administration, and lack of knowledge. Some common types of errors are incorrect dose, wrong drug, wrong patient, and omission. To reduce errors, it is important to follow procedures like checking patient identity, having dosages double checked, using electronic systems, and minimizing distractions during administration. When errors occur, they must be promptly reported and an incident report filed to evaluate what went wrong and prevent future errors.
Medication error- In Multidisciplinary Hospital
An Introduction to Medication Error - Types, Subtypes, Professionals Involved, Causes, Prevention and its Reduction.
Med safety nj ph a 10 10 11 final 3 (97-2003)
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.
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The Medication Safety Code
Medication errors in Pediatrics
This document discusses medication errors in pediatrics. It defines key terms like adverse drug reactions, side effects, and prescribing errors. Medication errors are common in pediatrics due to dosing challenges from weight-based calculations and off-label use. Common causes of errors include human factors like fatigue, workplace issues like distractions, and drug factors like confusing labels. Preventing errors involves standardized processes, clear communication, limiting verbal orders, confirming patient identity, and involving pharmacists. Nursing students and faculty have specific responsibilities when administering medications to ensure safety. The goal is to establish best practices to minimize harmful medication errors in children.
Pharmacovigilance orientation
This document discusses the importance of adverse drug reaction (ADR) monitoring and pharmacovigilance. It notes that while clinical trials reveal most common and acute ADRs, post-marketing surveillance is needed to detect rare or delayed reactions since drugs are used by larger and more diverse populations in clinical practice. The document outlines how to report ADRs to monitoring centers, methods to assess causality, the role reporting plays in regulatory actions like changing drug labels or restrictions, and common reasons why ADRs may not always be reported. It emphasizes that joining efforts to share ADR reports can help deliver safer medications to patients.
Medication Error a pharmacist perspective 2-23-01
Medication errors are a serious and preventable issue that cause many deaths each year. Root causes are complex systems with multiple layers and disciplines involved in the medication use cycle. Common types of errors include look-alike or sound-alike drug names, confusing abbreviations, incorrect dosages, and improper packaging or labeling. Strategies to prevent errors include identifying high alert medications, improving order entry processes, and redesigning systems with safety as a priority.
Medication errors
Easiest way to learn about Medication error, Types of medication Error and reporting of Medication error
Medication error- Etiology and strategic methods to reduce the incidence of M...
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 as per 5th Edition Standard of NABH
This presentation tells us about what are the medication errors and how we differentiate between them as per the National Accreditation Board for Hospital & Healthcare Providers standard for hospitals 5th Edition.
Presentation contains detailing details of medication error.
Some GIFs may not be seen.
Preliminary study of Prescription audit for evaluation of prescribing pattern...
Prescription audit is necessary to know the art of prescription practices to improve rational pharmacotherapy.
Present study is an observational study and was undertaken from August 2018 to October 2018 for which data
was collected from Medical OPD. Prescribing is a technique with an expert academic pharmacological
knowledge.
Irrational prescribing leads to diminished therapeutic outcome. The present study is the first preliminary one at
Pandit Jawaharlal Lal Nehru Govt. Medical College and Hospital, Chamba- HP Before July 2016, it was a
district hospital College. It is a hilly district and caters the need of 5 Lakh people. A total of 420 prescriptions
were analyzed. These prescriptions comprised of 3000 drugs. Average drugs prescribed per patient were 7.3 .
male and female ratio was 40% and 60% respectively. More prescription were carried out in the age group of 51
- 60 yrs. Prescriptions in generic were only 3.65% fixed dose combination was used in 300 prescriptions and
comprised of 71.4% drugs. Oral prescriptions were used maximally and intravenous medication was minimally
used. Multivitamin prescriptions were observed in bulk.
Medication safety 2011
This document discusses medication errors, including definitions of key terms like adverse drug events and adverse drug reactions. It provides classifications and reasons for medication errors, as well as methods to prevent, identify, and minimize errors. These include implementing systems-based approaches, reducing reliance on memory through automation, standardizing processes, and employing checks and policies. Reporting of medication errors is also addressed.
THE IMPACT OF CLINICAL PHARMACIST IN DETECTION OF
This study analyzed medical records from 80 patients at an internal medicine department in Zagazig, Egypt to identify drug-related problems. The study found that 66.2% of patients experienced drug-drug interactions, with the most common being moderate in severity and fair reliability. Errors included high doses, inappropriate frequencies, and wrong or duplicate drugs. The study recommends including clinical pharmacists in prescribing and monitoring to reduce errors and establish treatment guidelines.
Medication error
1. A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of a healthcare professional, patient, or consumer.
2. Medication errors can occur at various stages including prescribing, transcribing, dispensing, administration, and monitoring of medication. Common causes include distractions, lack of knowledge, incomplete patient information, and systemic issues.
3. When a medication error occurs, the patient's safety is the top priority and the error must be reported according to the institution's policies to help prevent future errors.
Guidelines peds preventing medication errors
This document provides guidelines for preventing medication errors in pediatric patients. It discusses how medication errors are usually the result of failures in healthcare systems rather than individual practitioners. It recommends organizational systems like computerized prescriber order entry and automated dispensing devices to help prevent errors, provided they are programmed carefully with pediatric considerations in mind. Specific recommendations are provided for functions of computerized ordering, programming automated devices, and using technologies like bar coding appropriately in pediatric settings. The goal is to establish redundant systems that can help shape behavior and minimize medication errors in children.
Falls prevention and the role of the pharmacist
This document discusses the role of pharmacists in falls prevention. It notes that patients on four or more medications are at greater risk of falls, and that regular medication reviews play an important part in reducing falls risk. The document outlines pharmacist interventions like screening for polypharmacy, assessing individual fall risks, prioritizing high-risk medications, and modifying treatment regimens through recommendations and education. It provides an example case study of a patient at risk of falls and how a pharmacist could support medication optimization and risk reduction.
Prabhjot Saini.pptx
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 Dr-Z Pharmacy Practice Lecture
This document discusses medication errors, including definitions, types, causes, and ways to improve safety. Some key points:
- Medication errors are preventable events that may harm patients and are caused by failures in prescribing, dispensing, administration, or monitoring.
- Errors can occur at various stages of the medication use process and be due to factors like high workload, look-alike drug names, and poor communication.
- High-risk medications like anticoagulants require special precautions. Healthcare professionals should know drugs well, use memory aids, and develop checking habits to minimize errors.
- Encouraging patient involvement, thorough documentation, learning from past errors, and clear communication can also
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What is a ‘medication error’
The document discusses medication errors, which are preventable failures in the treatment process that can harm patients. It defines medication errors and classifies them by cause, stage of occurrence, and severity of harm. Prescribing errors are the most common, followed by administration and dispensing errors. Technologies like computerized prescribing and barcoding can reduce errors but implementing them faces challenges. Improving handwritten prescription quality, such as using standard formats and avoiding ambiguous abbreviations, also aims to reduce errors. The conclusion emphasizes that both technological solutions and improving manual processes are needed to enhance patient safety by reducing medication errors.
Polypharmacy in elderly patients:an intervention study in therapeutic management
Oral presentation, 21° WONCA World Conference of Family Doctors, 3 november 2016, Rio de Janeiro, Brazil
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This gives information about what are medication errors, causes, Levels and Approaches to evaluate and Minimize them
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Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
Medication errors
Medication errors can occur at various stages including prescribing, dispensing, and administration. They are caused by factors like illegible handwriting, confusion between drug names, interruptions during administration, and lack of knowledge. Some common types of errors are incorrect dose, wrong drug, wrong patient, and omission. To reduce errors, it is important to follow procedures like checking patient identity, having dosages double checked, using electronic systems, and minimizing distractions during administration. When errors occur, they must be promptly reported and an incident report filed to evaluate what went wrong and prevent future errors.
Medication error- In Multidisciplinary Hospital
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Med safety nj ph a 10 10 11 final 3 (97-2003)
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.
The Medication Safety Code initiative: Towards a global IT system for persona...
We are creating a barrier-free system for storing and interpreting personal pharmacogenomic information:
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Medication errors in Pediatrics
This document discusses medication errors in pediatrics. It defines key terms like adverse drug reactions, side effects, and prescribing errors. Medication errors are common in pediatrics due to dosing challenges from weight-based calculations and off-label use. Common causes of errors include human factors like fatigue, workplace issues like distractions, and drug factors like confusing labels. Preventing errors involves standardized processes, clear communication, limiting verbal orders, confirming patient identity, and involving pharmacists. Nursing students and faculty have specific responsibilities when administering medications to ensure safety. The goal is to establish best practices to minimize harmful medication errors in children.
Pharmacovigilance orientation
This document discusses the importance of adverse drug reaction (ADR) monitoring and pharmacovigilance. It notes that while clinical trials reveal most common and acute ADRs, post-marketing surveillance is needed to detect rare or delayed reactions since drugs are used by larger and more diverse populations in clinical practice. The document outlines how to report ADRs to monitoring centers, methods to assess causality, the role reporting plays in regulatory actions like changing drug labels or restrictions, and common reasons why ADRs may not always be reported. It emphasizes that joining efforts to share ADR reports can help deliver safer medications to patients.
Medication Error a pharmacist perspective 2-23-01
Medication errors are a serious and preventable issue that cause many deaths each year. Root causes are complex systems with multiple layers and disciplines involved in the medication use cycle. Common types of errors include look-alike or sound-alike drug names, confusing abbreviations, incorrect dosages, and improper packaging or labeling. Strategies to prevent errors include identifying high alert medications, improving order entry processes, and redesigning systems with safety as a priority.
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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 as per 5th Edition Standard of NABH
This presentation tells us about what are the medication errors and how we differentiate between them as per the National Accreditation Board for Hospital & Healthcare Providers standard for hospitals 5th Edition.
Presentation contains detailing details of medication error.
Some GIFs may not be seen.
Preliminary study of Prescription audit for evaluation of prescribing pattern...
Prescription audit is necessary to know the art of prescription practices to improve rational pharmacotherapy.
Present study is an observational study and was undertaken from August 2018 to October 2018 for which data
was collected from Medical OPD. Prescribing is a technique with an expert academic pharmacological
knowledge.
Irrational prescribing leads to diminished therapeutic outcome. The present study is the first preliminary one at
Pandit Jawaharlal Lal Nehru Govt. Medical College and Hospital, Chamba- HP Before July 2016, it was a
district hospital College. It is a hilly district and caters the need of 5 Lakh people. A total of 420 prescriptions
were analyzed. These prescriptions comprised of 3000 drugs. Average drugs prescribed per patient were 7.3 .
male and female ratio was 40% and 60% respectively. More prescription were carried out in the age group of 51
- 60 yrs. Prescriptions in generic were only 3.65% fixed dose combination was used in 300 prescriptions and
comprised of 71.4% drugs. Oral prescriptions were used maximally and intravenous medication was minimally
used. Multivitamin prescriptions were observed in bulk.
Medication safety 2011
This document discusses medication errors, including definitions of key terms like adverse drug events and adverse drug reactions. It provides classifications and reasons for medication errors, as well as methods to prevent, identify, and minimize errors. These include implementing systems-based approaches, reducing reliance on memory through automation, standardizing processes, and employing checks and policies. Reporting of medication errors is also addressed.
THE IMPACT OF CLINICAL PHARMACIST IN DETECTION OF
This study analyzed medical records from 80 patients at an internal medicine department in Zagazig, Egypt to identify drug-related problems. The study found that 66.2% of patients experienced drug-drug interactions, with the most common being moderate in severity and fair reliability. Errors included high doses, inappropriate frequencies, and wrong or duplicate drugs. The study recommends including clinical pharmacists in prescribing and monitoring to reduce errors and establish treatment guidelines.
Medication error
1. A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of a healthcare professional, patient, or consumer.
2. Medication errors can occur at various stages including prescribing, transcribing, dispensing, administration, and monitoring of medication. Common causes include distractions, lack of knowledge, incomplete patient information, and systemic issues.
3. When a medication error occurs, the patient's safety is the top priority and the error must be reported according to the institution's policies to help prevent future errors.
Guidelines peds preventing medication errors
This document provides guidelines for preventing medication errors in pediatric patients. It discusses how medication errors are usually the result of failures in healthcare systems rather than individual practitioners. It recommends organizational systems like computerized prescriber order entry and automated dispensing devices to help prevent errors, provided they are programmed carefully with pediatric considerations in mind. Specific recommendations are provided for functions of computerized ordering, programming automated devices, and using technologies like bar coding appropriately in pediatric settings. The goal is to establish redundant systems that can help shape behavior and minimize medication errors in children.
Falls prevention and the role of the pharmacist
This document discusses the role of pharmacists in falls prevention. It notes that patients on four or more medications are at greater risk of falls, and that regular medication reviews play an important part in reducing falls risk. The document outlines pharmacist interventions like screening for polypharmacy, assessing individual fall risks, prioritizing high-risk medications, and modifying treatment regimens through recommendations and education. It provides an example case study of a patient at risk of falls and how a pharmacist could support medication optimization and risk reduction.
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Polypharmacy in elderly patients:an intervention study in therapeutic management
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Medication error- Etiology and strategic methods to reduce the incidence of M...
Medication Error as per 5th Edition Standard of NABH
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Similar to medical error
Prabhjot Saini.pptx
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.
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This document discusses medication errors, including definitions, types, causes, and ways to improve safety. Some key points:
- Medication errors are preventable events that may harm patients and are caused by failures in prescribing, dispensing, administration, or monitoring.
- Errors can occur at various stages of the medication use process and be due to factors like high workload, look-alike drug names, and poor communication.
- High-risk medications like anticoagulants require special precautions. Healthcare professionals should know drugs well, use memory aids, and develop checking habits to minimize errors.
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Medication Safety Policy
1. The document discusses medication safety policies and reducing medication errors. It identifies the top 10 medications commonly involved in errors in hospitals in the US and potential causes of errors during prescribing, dispensing, and administration.
2. Recommendations are provided for safer practices across the medication use process from prescribing to administration. This includes reducing reliance on memory, standardizing processes, improving communication, and automating where possible.
3. Specific high-risk populations like pediatrics, geriatrics, and those with allergies are addressed. Key strategies proposed include standardized documentation, education of patients and caregivers, and enhanced monitoring for adverse events.
ME and HAM.ppt
Medication errors are preventable events that can harm patients. They occur frequently due to look-alike and sound-alike drug names, improper dosing, and other issues. Reporting medication errors is important to identify root causes and improve safety. High alert medications require extra precautions like independent checks and labeling to prevent harmful errors. Reducing distractions, improving communication, and ensuring proper training can help reduce medication errors.
Medication errors.pptx
Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm. They can occur at any stage from prescribing to administration. Common factors that influence errors include lack of training, complex medication regimens, distractions, and look-alike drug names. Prescribing errors involve incorrect drug selection or dosing, while dispensing errors provide the wrong drug. Administration errors occur when the patient receives an incorrect medication. Reducing errors requires improved education, standardized processes, technology support like computerized prescribing, and checking procedures.
Medication error
Medication Error is any unwanted event which happen when the drug is in the control of the healthcare professional.
Final dissertation
This document discusses medication errors that can occur in hospitals. It defines medication errors as any error in prescribing, dispensing, or administering drugs, regardless of whether harm occurs. Medication errors are a major cause of preventable patient harm. The document classifies medication errors as mistakes, slips, or lapses, depending on where the error occurs in the medication use process. It also discusses different ways medication errors have been estimated to cause deaths in other countries to highlight the significant impact of these errors.
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Safety measures while using medicine
This document discusses safety measures for using medication and outlines key factors that can lead to medication errors. It defines medication errors and adverse drug events, and identifies high-alert medications and black box drug warnings. The five stages of the medication process are described as well as common types of errors that can occur at each stage, particularly prescribing and administering. Working conditions like staffing shortages, distractions, and high workloads are highlighted as latent factors that can facilitate medication errors.
Rational use of drugs -1
This document outlines the topics that will be covered in the Clinical Pharmacy II course, including rational use of drugs, rational prescribing, rational dispensing, problems of irrational drug use, and factors causing irrational drug use. It provides the course contents, marking scheme, topics to be covered, and expected learning outcomes. The key areas of focus for rational use of drugs are ensuring patients receive appropriate medications to meet their clinical needs at the lowest possible cost. Rational prescribing involves selecting drugs based on safety, effectiveness, tolerability, price and simplicity, while rational dispensing aims to provide patients with adequate counseling and instructions for proper medication use. Irrational drug use can result from improper prescribing, dispensing, or non-adherence and lead to negative
Current Situation of Medical ErrorsPrepared byAs
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.
Type ...
Medication Error Reporting.pptx
This document discusses medication errors, including definitions, types, contributing factors, detection, reporting processes, and prevention. The key points are:
- Medication errors are preventable events that may harm patients and are caused by mistakes in prescribing, dispensing, or administering drugs.
- Common types of errors include prescription errors, dispensing errors, administration errors, and transcription errors.
- Factors like look-alike drug names, poor communication, and environmental distractions contribute to errors.
- Errors can be detected through methods like medical rounds, medication administration records, and analyzing returned doses.
- Reporting helps identify root causes and improve safety, but relies on voluntary participation and protecting confidentiality
medication error.pptx
This document provides an overview of medication safety and medication errors. It defines key terms like medical error, adverse drug events, and near misses. It discusses the scale of medication errors, estimating they occur in 5-14% of doses dispensed and 1 in 100 result in an adverse drug event. Preventable medical errors occur in over 3 million hospital admissions and outpatient visits annually in the US, resulting in over 7,000 deaths each year. Factors that contribute to medication errors include complex medication regimens and lack of communication between healthcare providers. Strategies to improve safety include using generic drug names, tailoring prescriptions to each patient, thorough medication histories, awareness of high-risk medications, and encouraging patient involvement.
P6 MEDICATION SAFETY HOUSEMANSHIP MALAYSIA
This document provides information on medication safety and reducing medication errors. It defines medication error, discusses the importance of medication safety and common causes of errors. It outlines the steps in medication use and types of errors that can occur. Contributing factors and strategies to reduce errors are presented, including the importance of the 5 rights of medication administration. High alert medications and look-alike sound-alike medications that require extra care are also described. The goal is to educate healthcare practitioners on medication safety best practices.
8.1 ADR_complete.pdf
This document discusses adverse drug reactions (ADRs), including:
1) Defining ADRs and distinguishing them from adverse drug events. ADRs are unintended effects caused directly by a drug, while adverse events can have other causes.
2) Around 5-10% of hospitalized patients experience an ADR, contributing to increased costs and length of stay. ADRs can reduce quality of life and rarely cause death.
3) Pharmacovigilance aims to detect, understand, and prevent ADRs through monitoring, reporting, and research on drug safety. Pharmacists play a key role in pharmacovigilance.
Medication Safety- Administration and monitoring.pptx
The document discusses medication safety and reducing medication errors. It covers several key points:
1) Medication errors are common, especially during transitions of care between settings. The WHO aims to reduce medication-related harm by 50% through their "Medication Without Harm" challenge.
2) Medication errors can occur at various stages like prescribing, transcribing, dispensing, and administering. High-risk medications and situations like polypharmacy also increase error risk.
3) Strategies to improve safety include training, protocols, technology like CPOE, reconciliation, and empowering patients. A multidisciplinary team approach is important to strengthen systems and practices.
Medication errors
This document discusses medication errors, including their definition, causes, types, and strategies to prevent them. Some key points:
- Medication errors are preventable events that may cause harm and can occur at any stage from prescribing to administration. They are common but underreported.
- Errors are often due to look-alike or sound-alike drug names, miscommunication, lack of knowledge, and environmental factors like interruptions.
- Common types of errors include prescribing errors, dispensing errors, and administration errors. Analgesics, antibiotics, anticoagulants are high-risk drug classes.
- Prevention strategies include education, standardized processes, double checks, limiting distractions, clear
Strategies to improve adherence to antihypertensive medication
Challenges in hypertension treatment.What is the definition of medication non-adherence?Who is at risk? How should
patients at risk be screened and identified?What are the negative impacts of non-adherence?What is the
practical approach for improving adherence? The ABC taxonomy for medication adherence
Adherence :3 quantifiable components: initiation , implementation , and discontinuationThe five dimensions
of non-adherence
.
PATIENT COMPLIANCE
DEFINITION
BACKGROUND
METHODS OF ASSESSING COMPLIANCE.
Factors concerned with compliance.
BARRIERS TO COMPLIANCE
IMPROVEMENT OF COMPLIANCE .
NON-COMPLIANCE FACTORS.
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Medication Safety- Administration and monitoring.pptx
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medical error
- 1. MEDICAL ERRORS Ms. Chanda Jabeen Lecturer RN, RM, BSN M.Phil. Epidemiology & Public Health PhD (Scholar) Epidemiology & Public Health 1
- 2. OBJECTIVES 1. Define the medical errors and medication error. 2. Explain the burden of the medication errors. 3. Explore the causes of medication errors. 4. Discuss the Swiss Cheese Model. 5. Discuss types of medication errors. 6. Explain Steps for prevention medication errors. 2
- 3. MEDICAL ERROR Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. For example: an adverse drug event, improper transfusion, surgical injuries and wrong site injuries, suicide, restraint-related injury or death, falls, burns, pressure ulcers and mistaken patient identity. At least 44,000- 98,000 people die in hospitals each year from preventable medical errors.
- 4. “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient, or consumer” • May occur at any time, from the prescription to consumption of the medicines by the patient . MEDICATION ERROR 4
- 5. BURDEN OF THE MEDICATION ERRORS. 5
- 6. Study conducted in Indonesia showed following results (Ernawati,Lee & Hughes, 2014). 6
- 7. 80,000 people annually died in the United States alone due to medication errors (Stoppler,2012). Medical errors are the eighth leading cause of death in this Pakistan and about 7,000 people per year are estimated to die from medication errors alone(The Nation,2011). In Pakistan the main error rate is 5.5% and pharmacists contributed a higher error rate of 2.6% followed by nurses (1.1%) and physicians (1%) (Khowaja et al.,2008). 7
- 8. According to a survey by European Commission (EC), the highest number of medical errors related incidents in hospitals are found in Latvia (32%), Denmark (29%) and Poland (28%) Austria tops the ranking having both the fewest medical errors in hospitals (11%) and in medical prescriptions (7%) (European Commission,2006). 8
- 9. • Errors of Omission: errors related to prescription, drug dispensing by pharmacist, drug administration by medical personnel like nurses & patient themselves • Errors of Commission: most common form of errors encountered in clinical practice, this include 1.)Wrong phenomenon 2.) Drug interaction related CAUSES OFERRORS 9
- 10. 3.) Communication failure 4.) Failure to follow appropriate policies related to drug use 5.) Failure to follow drug-specific instructions 6.) Overuse of a drug(irrational drug use & polypharmacy) CAUSES OFERRORS 10
- 11. • Some other recognized types of medication errors- Incomplete patient information Drug information unavailable Miscommunication of drugorders Confusion in drugnames Misuse of zeros & decimal points Confusion in dosingunits Inappropriate abbreviations 11
- 12. SWISSCHEESEMODEL 12 • Pictorial model formedication errors • Defences against error displayed asthin layers with holes that describes latent errors in system • Eachlayer successively represents the prescriber, pharmacist, nurse & patient related defences • Missed error successively at various defence levels, reaches the patient
- 13. 13
- 15. PRESCRIBINGERRORS Incorrect drug selection for a patient Errors in quantity, indication Prescribing of a contraindicated drug 15
- 17. DRUG ADMINISTRATION ERRORS Failure to check the patient’s identity priorto administration Environmental factors such a noise, interruptions ,poor lighting Wrong calculation to determine the correct dose 17
- 18. STEPSTOBETAKENIN PREVENTING MEDICATION ERROR Follow the rights of medication administration •Right patient •Right drug •Right dose •Right time •Right route 18
- 19. STEPSTOBETAKENIN PREVENTING MEDICATION ERROR •Right recording •Right assessment •Right education •Right evaluation •Right to refuse medication 19
- 20. REFERENCES Ernawati, D. K., Lee, Y. P., & Hughes, J. D. (2014). Nature and frequency of medication errors in a geriatric ward: an Indonesian experience. Therapeutics and clinical risk management, 10, 413. European Commission (EC). (2006). Medical Errors. Retrieved fromhttp://ec.europa.eu/public_opinion/archives/ebs/ebs_ 241_en.pdf Khowaja, K., Nizar, R., Merchant, R. J., Dias, J., Bustamante- Gavino, I., & Malik, A. (2008). A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan. Therapeutics and clinical risk management, 4(4), 673. 20
- 21. REFERENCES Stoppler,M.C.(2012).The most Common Medication Errors. MedicineNet.com. Retrieved from URL: http://www.medicinenet.com/script/main/art.a sp?articlekey=55234 Singh,I., Shafiq,N.,& Malhotra, S.(2011). Medication Errors: Causes & its prevention. Drugs Bulletin,2. The Nation.(2011). On medical errors. Retrieved from URL: http://www.nation.com.pk/pakistan-news-newspaper- daily-english-online/letters/30-Dec 21