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.
The existence of look alike and sound alike drug names is a one of the most common causes of medication error and is of concern worldwide. As more medicines and new brands are being marketed in addition to the thousands already available. Many of these medication names may look or sound alike. Thus, the potential for error due to confusing drug names is very high. According to the survey from United States Pharmacopoeia, around commonly used medications were involved in such errors. Error prone medication pairs that can easily cause confusion while prescribing, dispensing and administration/consumption were sorted out. Also real life experiences of medication errors and near misses due to error prone drug pairs were collected from the doctors and the dispensers. It is very important that we circulate the list of confusing brand names among the practicing doctors, pharmacists and also to the drug manufacturers. Preventing confusion between already marketed products typically involves collecting voluntary reports of names involved in confusion errors, posting warnings and alerts both electronically and in areas where drugs are used. The fear of malpractice lawsuits and public embarrassment has made the physicians and nurses reluctant to report medication errors. It is more important to create the open environment that encourages the reporting of errors than to develop less meaningful comparative error rates. One possible approach to improving medical error reporting systems. This type of system should also enable internal tracking, trending and comparative analyses. We need to have such system in India.
Medications are a critical component of the care provided to patients and are used for diagnostic, symptomatic,
preventive, curative, and palliative treatment and management of diseases and conditions. A medication
system that supports optimal medication management must include processes that support safe and effective
medication use. Safe, effective medication use involves a multidisciplinary, coordinated effort of health care
practitioners applying the principles of process design, implementation, and improvement to all aspects of
the medication management process, which includes the selecting, procuring, storing, ordering/prescribing,
transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medication
therapies
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.
Learn best practices based on literature and how to perform a complex and accurate medication history. Recognize gaps/inconsistencies in systems that impede medication reconciliation and identify next steps in improving current medication reconciliation within your own practice.
Speaker:
Mary Pat Friedlander, MD
Lawrenceville Family Health Center
Pittsburgh, PA
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
The existence of look alike and sound alike drug names is a one of the most common causes of medication error and is of concern worldwide. As more medicines and new brands are being marketed in addition to the thousands already available. Many of these medication names may look or sound alike. Thus, the potential for error due to confusing drug names is very high. According to the survey from United States Pharmacopoeia, around commonly used medications were involved in such errors. Error prone medication pairs that can easily cause confusion while prescribing, dispensing and administration/consumption were sorted out. Also real life experiences of medication errors and near misses due to error prone drug pairs were collected from the doctors and the dispensers. It is very important that we circulate the list of confusing brand names among the practicing doctors, pharmacists and also to the drug manufacturers. Preventing confusion between already marketed products typically involves collecting voluntary reports of names involved in confusion errors, posting warnings and alerts both electronically and in areas where drugs are used. The fear of malpractice lawsuits and public embarrassment has made the physicians and nurses reluctant to report medication errors. It is more important to create the open environment that encourages the reporting of errors than to develop less meaningful comparative error rates. One possible approach to improving medical error reporting systems. This type of system should also enable internal tracking, trending and comparative analyses. We need to have such system in India.
Medications are a critical component of the care provided to patients and are used for diagnostic, symptomatic,
preventive, curative, and palliative treatment and management of diseases and conditions. A medication
system that supports optimal medication management must include processes that support safe and effective
medication use. Safe, effective medication use involves a multidisciplinary, coordinated effort of health care
practitioners applying the principles of process design, implementation, and improvement to all aspects of
the medication management process, which includes the selecting, procuring, storing, ordering/prescribing,
transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medication
therapies
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.
Learn best practices based on literature and how to perform a complex and accurate medication history. Recognize gaps/inconsistencies in systems that impede medication reconciliation and identify next steps in improving current medication reconciliation within your own practice.
Speaker:
Mary Pat Friedlander, MD
Lawrenceville Family Health Center
Pittsburgh, PA
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
Clinical errors by nursing / paramedic staffMohit Changani
Nursing staff care is very critical for the management of any patient. Nursing staff need to be specific and punctual in providing care. This presentation deals with common clinical errors that might be occurring on the care provided by nursing or paramedic staff
Medication safety and Prevention of Medication errors.pptxsats81
The topic is related to pharmacology in nursing. The topic concretely described about common medical errors in medication prescription and administration .The topic also include how we can prevent medication errors at different stages of emdication dispensing.
The Emerging Role of Pharmacists in Public Health.pptxDr. Ankit Gaur
The Emerging Role of Pharmacists in Public Health: Opportunities and Challenges
General system theory, steven's system model, Pharmacists in india, Disaster management and emergency care, rational use of medicine, RNTCP programme. National Aids Control Programme.
This presentation is about Stress and its impact on health. I have tried to cover everything related to it, stressors, coping mechanisms, tools, types etc.
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
In this presentation I have tried to discuss in brief about obsessive compulsive disorder and its treatment both pharmacological and non pharmacological.
In this presentation I have tried to explain in brief about pain management, different types of pain, its diagnostic criteria, its physiology, and its treatment approaches both pharmacological and non pharmacological
Respiratory Tract Infections- A Pharmacotherapeutic ApproachDr. Ankit Gaur
In this presentation I have tried to explain the types, etiology, pathophysiology of respiratory tract infections such as bronchitis, pnemonia, otitis media, sinusitis, pharyngitis, and their treatment
In this presentation I have tried to explain in brief about the dosage adjustment in renal disorders, how to carry out this process and the important formulae which are used in it.
In this presentation i have tried to explain in brief about nomograms and their applications, the general approach to individualise doage regimen by using pharmacokinetic data
In this presentation I have tried to explain in detail about tablets, their different types, ingredients which are used to prepare them, and the procedure to prepare them as well. This presentation is very useful for pharmacy students.
In this presentation i have tried to explain in details about the Total Parenteral Nutrition (TPN) , what is it, who needs it, and how to prepare it and the necessary procedure with instructions. It is very useful for the individuals from Nutrition, Nursing, Pharmacists, and Medical background.
in this presentation i have tried to briefly discuss about diuretics (water pills), their classification, mechanism of action, pharmacokinetics and pharmacodynamics of these drugs
In this presentation i have tried to explain in brief about CPR, how and when it has to be done and the important things to be kept in mind while doing it. This ppt is very helpful for every individual who is looking for the info regarding CPR.
In this presentation i have tried to explain in detail about the nux vomica and khurchi bark. This presentation is useful for the individuals who are looking for information on this topic especially for those students who are studying Pharmacognosy.
In this presentation i have tried to explain in detail about the measurements of the outcomes which are used in epidemiology such as prevalence, incidence, fatality rate, crude death rate etc.
In this presentation i tried to explain in detail about cohort studies, their types, how to conduct them, their outcomes, and how to calculate sample size of these studies.
In this presentation i have tried to thoroughly discuss about the concept of Drug induced kidney disease or injury, the mechanism behind it, its classification and how to access it.
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
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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.
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.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
2. "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 professional
practice, health care products, procedures,
and systems, including prescribing; order
communication; product labeling, packaging,
and nomenclature; compounding; dispensing;
distribution; administration; education;
monitoring; and use."
3. • Human-related
• System-related
• Medication-related
Near Miss (Medication Error): Medication error
that took place but captured before reaching
to the patient. Such events have also been
termed as ‘near miss’ Medication error.
4. Providers
Over-worked
Under-trained
Competence
Distracted
Illness
Stressed
Patients
In a hurry
Health literacy
level
Do not understand
the
medication/use
Trust providers to
not make mistakes
5. Lack of communication
Poor workflow
Disorganized workspace
Inadequate tools to complete work
Lack of supervision
7. • Right Drug
• Right Route
• Right Time
• Right Dose
• Right Patient
• Right Dosage Form
World Health Organization WHO, Patient Safety Curriculum Guide
9. Prescribing error: A clinically meaningful
prescribing error occurs when, as a result of a
prescribing decision or prescription writing
process, there is an unintentional significant (1)
reduction in the probability of treatment being
timely and effective or (2) increase in the risk
of harm when compared with generally
accepted practice” .
It includes:
Incorrect Prescription
Illegible Handwriting
Drug allergy not identified
Irrational combinations
Out of list abbreviations
10.
11.
12. A dispensing error is a discrepancy between
a prescription and the medicine that the
pharmacy delivers to the patient or
distributes to the ward on the basis of this
prescription, including the dispensing of a
medicine with inferior pharmaceutical or
informational quality
13. 98.3% accuracy in dispensing medications
Therefore, 1.7% inaccuracy rate
Over 3 billion medications dispensed per year
4 errors per day per 250 prescriptions filled
Over 51 million dispensing errors per year
Flynn E, et al. J Am Pharm Assoc. 2003;43:191–200.
14. Dispensing incorrect medication, dosage
strength, or dosage form
Dosage miscalculations
Failure to identify drug interactions or
contraindications
16. Failure to counsel the patient
Failure to screen for interactions and
contraindications
17. Miscalculation of a dose
Dispensing the incorrect medication,
dosage strength, or dosage form
18. Work environment
Workload
Distractions
Work area
Use of outdated or incorrect
references
LASA drugs (Look Alike Sound Alike)
19. A physician writes an order for primidone
(Mysoline) for a 12-year old boy with a
seizure disorder. Misreading the physician’s
handwriting, the pharmacist mistakenly fills
the order with prednisone. For 4 months, the
boy receives prednisone along with his
seizure medications, causing steroid-induced
diabetes. The diabetes goes unrecognized,
and he dies from diabetic
ketoacidosis…because the drug was LASA
drug that lead to Dispensing Error
22. A drug administration error may be defined
as a discrepancy between the drug therapy
received by the patient and the drug therapy
intended by the prescriber.
Administration errors account for 26% to 32%
of total medication errors.
It involved wrong patient, wrong route of
administration, wrong drug, wrong dose,
wrong method, wrong time.
23. Lack of perceived risk
Lack of available technology
Lack of knowledge of the preparation or
administration procedures Complex design of
equipment.
CONTRIBUTING FACTORS TO DRUG
ADMINISTRATION ERRORS: Failure to check
the patient’s identity prior to administration
Environmental factors such a noise,
interruptions ,poor lighting Wrong calculation
to determine the correct dose
24. A critical care nurse tries to catch up with her
morning medications after her patient’s
condition changes and he requires several
procedures. He is intubated, so she decides to
crush the pills and instill them into his
nasogastric (NG) tube. In her haste to give the
already-late medications, she fails to notice the
“Do not crush” warning on the electronic
medication administration record. She crushes
an extended-release calcium channel blocker
and administers it through the NG tube. An hour
later, the patient’s heart rate slows to asystole,
and he dies…because of Administration error
25. Transcription is a process of making an identical copy
of prescription in the medical records. Error that
occurs during this process is known as Transcription
Error.
Several sheets of paper and stages from physician’s
order to drug delivery may cause confusion and add
to the possibility of transcription errors.
Contributing factors include incomplete or illegible
prescriber orders; incomplete or illegible nurse
handwriting; use of abbreviations; and lack of
familiarity with drug names.
In addition to errors associated with transcribing the
drug name, there is also opportunity for errors when
transcribing the dose, route or frequency.
26. Error that occurs during the process of
indenting
It includes wrong drug, wrong strength,
Wrong dose, Wrong route and frequency.
27. Category Event
A Circumstances or event that has a
capacity to cause error.
B Error occurred but didn’t reach the
patient.
C An error occurred that reached the
patient but did not cause any harm.
D An error occurred that reached the
patient and required monitoring to
confirm that it resulted in no harm to the
patient and /or required intervention to
preclude harm.
E An error occurred that may have
contribute to or resulted in temporary
harm to the patient and required
intervention.
28. Category Event
F An error occurred that may have
contribute to or resulted in temporary
harm to the patient and required transfer
to other unit/critical care.
G An error occurred that may have
contribute to or resulted in permanent
harm of the patient.
H An error occurred that required
intervention to sustain life.
I An error occurred that may have
contribute to or resulted in patient.