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 error- Etiology and strategic methods to reduce the incidence of M...Dr. Jibin Mathew
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer
Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.
Medication error- Etiology and strategic methods to reduce the incidence of M...Dr. Jibin Mathew
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer
Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.
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.
Type ...
Medication therapy is becoming increasingly more complex as new drugs are developed and more therapeutic targets are elucidated. In addition, polypharmacy (≥5 scheduled medications) has become exceedingly common in geriatric patients and in patients with chronic disease states. As the complexity of drug therapy and the number of medications increase, patients are at a high risk for medication errors and adverse drug events (ADEs), or injuries resulting from medication. The type of adverse events may be associated with professional practices, healthcare products, procedures, and systems including prescription, communication through instructions, drug labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring, and use. Classification and evaluation of medication errors according to their importance may constitute an important factor for process improvement in order to render the administration of medicines as safe as possible. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Technology has grown to be a constituent part of medicine these days. A few advantages that technology can supply are categorized as follows: the assisting of communication between clinicians; enhancing medication safety; decreasing potential medical errors and adverse events; rising access to medical information and encouraging patient-centered healthcare. The aim of this article is to provide a compendious literature review regarding Medication errors
5 annotated bibliographies #1 As much as we try to preve.docxtroutmanboris
5 annotated bibliographies
#1
As much as we try to prevent them, medication errors happen everyday. It is especially
common in skilled nursing facilities because many of them still use paper charts for
medication administration or documentation and do not have access to the newer
technology that other medical facilities do.
According to a study performed in 2014, medication distribution technology has been
proven to be effective in automatically detecting medication errors so that nurses can
have more of an opportunity to focus on their patients. Working on a long-term care unit,
most of my time is spent passing medications and doing treatments since I have 19
residents to tend to. Depending on how “smooth” the night goes, I sometimes do not get
a chance to spend that extra time with my residents as I would like to. This medication
distribution technology includes a mobile medication dispensing cart for long-term care
units. The medications would be pre-packed for each patient by the pharmacy and able
to be dispensed when needed. This would allow nurses to provide more one-on-one
time with their patients while also increasing the prevention of medication errors. It also
will help to lighten the nurses’ workload. Research shows that these mobile medication
cart have been successful. Medication error rates decreased from 2.9% to 0.6% (Baril,
Gascon & Brouillette, 2014).
Reference
Baril, C., Gascon, V., & Brouillette, C. (2014). Impact of technological innovation on a
nursing home performance and on the medication-use process safety. Journal of
Medical Systems, 38(3), 1–12. https://library.neit.edu:2404/10.1007/s10916-014-0022-4
#2
Adverse drug effects due to medication errors are estimated to cost the United States
$2 billion every year. After reviewing patient reports and reviewing charts, it was
discovered that 44% of these occur after the prescription was written. These errors were
found to be from registered nurses, licensed practical nurses and pharmacy technicians.
Therefore, the problem comes from administration of the medication. However, these
numbers only account for the errors that are actually reported. It is the more serious and
harmful errors that are recorded, probably because they are harder to hide. The Health
Care Finance Administration of the United States made it standard for hospitals and
skilled nursing facilities to have no more than 5% of medication error rates a year.
In a study conducted in 2014, researchers decided to put a hold on reviewing incident
reports and patient charts. Instead, they decided to directly observe medication
administration over 20 different hospitals or skilled nursing facilities. Other methods
included: attending medical rounds to see if a medication error had occurred,
interviewing health care workers to see if they would report anything, testing patients
urine to see if they had any unauthorized medications in their system, and comparing .
Most people have been accustomed to believe that "Size Matters”. Men experience stress if they feel they fall short of average size. Men tend to conceptualize that they will be more attractive to their counterpart (partner) (or perceived to be more manly/masculine) if they possess a larger penile size. However, this is largely untrue.
It is essential to keep in mind that there is no “normal” when it comes to size of penis. Too small or too large penis occupy only 1% of the population while rest lie at average size. Concern about the penile size can be of major stress and may proceed to have sexual dysfunction in men who tend to think that they have small penis. The major dilemma is that many men perceive that the "average penis" is actually larger than what they actually possess. Various research studies reveal that female counterparts inclined to prefer penises of average size as compared to a large penis.
Once a male completes his puberty, the penis size is more or less "set." According to a research study conducted in 2014 on more than 15,000 men published in The British Journal of Urology, the average size of flaccid penis is 3.61 inches long and 3.67 inches in circumference, while the average size of erect penis coming in at 5.17 inches long and 4.59 inches in circumference.
It’s interesting to know that, even though the official averages are revealed, it doesn’t mean a man’s penis will be of exactly same size at every moment in his life. While most men would rather be a bit above average than below, there’s nothing wrong with having a penis below the average size – it is an average after all, so 50% of men will. Having a larger penis may not always be a good thing. In fact, a 2015 study found that, among 75 women surveyed, one of every 15 had left a relationship because their partner's penis size was "too large”
Women perceive penis size much differently than men do. What men think is small, she probably perceives as average, and what he consider average, she probably thinks is pretty big. That’s because unlike men, she doesn’t experience any penis size related anxiety.
Moreover a women’s vagina is only around 3 or 4 inches, which may expand to 4 or 5 when a woman is aroused. Too big size could be discomfort and painful. A larger penis poses similar risks in MSM who have anal sex, including an increased risk of HIV.
In a study of heterosexual people published in the British Journal of Urology International, 85% of women were satisfied with the size of their partner’s penis, while 45% of men thought that their own penis was too small. It is important to remember there is no “normal” when it comes to penis size. Remember that penis shouldn’t control one’s life, and hopefully, some of the researches prove that a below-average penis is not the end of the world and larger size doesn’t bring all the sexual pleasures. But if you’re truly unsatisfied, there are safe and effective ways to increase the size of your penis – its not end of the world
Constipation is the symptom and is associated with primary & Secondary causes. Constipation is defined as occurrence of >3 episodes of bowel movements. the Rome III criteria defines the objective classification and bristol stool chart helps in assessing the type of stools passed. Management of constipation deals with early assess, treating the cause, adjuvant management, Pharmacological Management (laxatives, suppositories & enemas) and following constipation prevention bundle.
High prevalence of hypertension in older persons (nearly one of two subjects aged >60 years). It is a significant and often asymptomatic chronic disease. HTN is a major cause of morbidity and mortality among aged. Hypertension in older adults is generally defined by SBP ≥ 140 mmHg or DBP ≥ 90 mmHg over two clinic visits (systolodiastolic HTN)
Isolated systolic hypertension (ISH): SBP of ≥140 with a DBP of <90 mm Hg.
The recognition and treatment of HTN should be a priority among elderly. Controlled, RCTs have shown that treatment of hypertension decreases the incidence of complications in older adults.
The COVID-19 infection is a double challenge for people with diabetes. Diabetes has been reported to be a risk factor for the severity of the disease. Much attention has been focused on people with diabetes because of poor prognosis in those with the infection. Initial reports were mainly on people with type 2 diabetes, although recent surveys have shown that individuals with type 1 diabetes are also at risk of severe COVID-19. The reason for worse prognosis in diabetes- multifactorial (syndromic nature of diabetes). Age, sex, ethnicity,comorbidities such as hypertension and cardiovascular disease, obesity, and a pro-inflammatory and pro-coagulative state all contribute to the risk of worse outcomes. Glucose-lowering agents and anti-viral treatments can modulate the risk
Introduction and pathophysiology of hypertension in elderly. Differences among hypertension in adults and elderly in terms of symptoms, treatment consideration. Issues and Challenges among elderly patients. Stroke among Elderly population. Issues and challenges in stroke elderly population.
Communication with ICU patients: Knowing their needsPrabhjot Saini
Need and barriers in Communication among ICU patients who are aphasic. Consequences of failed communication. Discussion on various methods and assistive devices to communicate. Discussion on the development & usability of a self structured communication chart as method of easy communication with ICU patients on ventilators.
Lifestyle modifications in Diabetes mellitusPrabhjot Saini
Lifestyle choices in Diabetes mellitus patients, current factors, Dietary modifications, exercises, alcohol and smoking cessation, stress management and personal and foot care required to manage diabetes and blood sugar levels
Brain Death concepts, Its changes and life after brain death, is the body still alive?? what are the determinants of brain death and who can declare it, bio ethical dimensions of nursing care in BD
Foe whatever the physical virtues of maleness, longeivity is not among them. Every year, almost 1,00,000 men are dying prematurely compared to 66,000 women. Women live longer than men
Evidence Based Nursing Practice: Current Scenario & eay forwardPrabhjot Saini
Explains about Research practice gap, present scenario, research utilization, constraints & barriers for research utilization, how to find evidences for EBP and strategiesto do it
Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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.
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.
1. Causes & Incidence of
Medication Error
DR. PRABHJOT SAINI BSN MSN PhD(N)
PROFESSOR & PRINCIPAL
SKSS COLLEGE OF NURSING
SARABHA, LUDHIANA, PUNJAB
email: psaini.dr@gmail.com , skssconsarabha@gmail.com
2.
3.
4. "To Err is Human“ - but not
at the cost of health of a
patient.
6. Medication Errors: Introduction
As many as 98,000 people die in any given year from medical errors that occur
in hospitals.
That's more than die from motor vehicle accidents, breast cancer, or AIDS.
Indeed, more people die annually from medication errors than from workplace
injuries.
7. The seriousness of medication error came to be known when
Institute of Medicine (US) stated in, “To Err is Human; Building a
Safer Health System,” that around 44,000 to 98,000 deaths in
America occurred as a result of medical errors.
The impact of medication error on patient's well-being is
unfathomable.
8.
9. Most of the medication errors do not cause any harm to the patient, but
there are some that cause unwarranted results, including
temporary or permanent harm to the patient's health and well-being
increased length of hospitalization
increase in cost of treatment
people losing faith in healthcare delivery system
and even deaths
10. A great need to break the silence that has surrounds medical errors and
their consequence.
Why these
mistakes
happen?
"How can we
learn from our
mistakes?"
11. How we define an error?
The word ERROR has drawn attention to "prevention"
According to Webster's New Collegiate Dictionary :
E.g. One can make An error of omission (failure to act correctly) Or An error of
commission (acted incorrectly)
Error is "an act that through ignorance, deficiency, or accident departs from or fails
to achieve what should be done is generally known as "the five rights": the right
Drug, right Dose, right Route, right Time, and right Patient.
12. Overview
What is medication error?
Incidence of medication errors
Causes of medication errors
Type of Medication errors
Factors contributing to Medication errors
Dangerous abbreviations
5 ‘High alert’ medications
Possible consequences of Medication errors
14. Medication error
An error in the prescribing, dispensing,
administration of a drug irrespective of whether
such errors lead to adverse consequences or not.
15. What is medication error?
The National Coordinating Council for Medication Error Reporting and Prevention
(NCCMERP) has defined medication error as
Thus, any medication error can be prevented before it may or may not cause harm to the
patient.
“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. These events may be related to professional practice, healthcare products,
procedures, and systems, including prescribing, order communication, product labeling,
packaging and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use”.1
16. Medication error in
developed countries
is of PRIMARY
CONCERN
Medication Error is
just a TERM and its
significance is
undervalued.
Developed Countries Vs Developing
Countries
17. Medication error: Underreported
Medication errors are routinely encountered but remain
underreported.
Reporting is important to thoroughly examine their contributing
factors and to implement preventive actions so as to avoid them
in future from happening.
18. Medication error: why Underreported ?
Perception 1: it may be considered to be no one's fault (Haw, Stubbs, &
Dickens, 2014) or part of normal practice (Soydemir et al., 2016).
For instance, the standard time for administration of a once-a-day medication
may be 8:00 a.m. at a particular institution. A nurse administers a patient's
morning medications at 2:00 p.m. because the patient was away from the unit
for a procedure. No medical order indicated medications should be withheld
until after the procedure. Having a seemingly valid excuse for late
administration of the medication does not make this any less a medication
error. This error may go unreported because it is seen as a normal part of care.
19. Medication error: why Underreported
Perception 2: An error does not need to be reported if it does not
seem to cause harm. Nurses typically do not report near misses or
errors if there are no serious consequences (Hashemi, Nasrabadi,
& Asghari, 2012; Kim et al., 2014; Wagner, Damianakis, Pho, &
Tourangeay, 2013).
In the above example, the nurse may believe no harm was done because the
patient did not develop any obvious complications and so may not report
this late administration as an error.
20. Medication error: why Underreported
Perception 3: Lack of a reporting system at an institution or lack
of staff awareness that a system for reporting exists (Lederman,
Dreyfus, Matchan, Knott, & Milton, 2013; Soydemir et al., 2016).
Perception 4: Fear of consequences if a medical error is reported
(Almutary, & Lewis, 2012; Haw et al., 2014; Kagan & Barnoy, 2013; Yung, Yu,
Chu, Hou, & Tand, 2016).
21. Need to be reported
The Institute of Medicine supported the concept of a culture of
safety to encourage error reporting without fear of repercussion or
blame
Reason:
So that root cause of errors could be identified and prevention
measures instituted (Kohn et al., 2000).
23. Incidence of medication Errors
Interesting but horrifying facts:
More people in USA die in a given year as a result of medical
errors than from motor vehicle accidents , cancers or AIDS
Majority are medication errors
Indian study of paediatric intensive care unit reported 68.5% of
all errors were medication errors
24. Incidence
Reported incidence of this iatrogenic disease related to medication error-
tip of the iceberg
Difficult to determine
Few studies provide complete evaluation of errors
Different methods to detect errors
Various definitions of errors
Large volumes of medication dispensed
Annual prescriptions approx. 3.54 billion
Small % of 3.54 billion is still large number
25. Indian Scenario
Prof Jha reported 5.2 million medical errors take place in India annually.
The British Medical Journal quoted that India, like any other developing country,
is witnessing a lot of medical errors.
The main reason being that we do not have trained doctors and nurses to
measure the clinical outcomes.
26. Incidence
Harvard medical practice study found 19% of adverse event in
hospitalized patients R/T drug complications
Error rates in outpatient pharmacies reported ~12% and in-hospital
~1 error per patient per day
19% of all doses were not administered correctly
43% of errors were due to wrong time of administration
27. ~1.5 million people are harmed by medications each year
Up to 400,000 of adverse events considered preventable
Medication error studies reported different rates (underreported,
different tools used)
Errors before medications reaching patient are not reported.
29. Swiss Cheese Model
Need to identify and address the root causes of medication errors
Can be done through continuous quality improvement (CQI).
Medication error has multiple causes—a series of mistakes, oversights
or system failures that combine to create risk for a patient.
This type of medication error can be visualized with the SWISS CHEESE
MODEL OF SYSTEM accidents
32. What is Swiss Cheese Model?
Pictorial model for medication errors
Several slices of Swiss cheese, each represent a different layer of prescriber,
pharmacist, nurse & patient related defenses or safeguards
Each layer has holes that reflect the inherent weaknesses in that particular
safeguard.
Normally, if one hole is penetrated, another slice (or safeguard) stops an error in its
tracks.
But what if the holes suddenly lined up? Now it’s as though there are no safeguards at all.
34. Medication error : As per Occurrence
Near Miss:
A Near-miss is an unplanned event that did not result in injury, illness,
or damage but had that the potential to do so.
Did not result in patient harm, but could be categorized as near-miss
Medication incident/ Sentinal event:
An unexpected incident, related to system or process deficiencies, which
leads to death or major and enduring loss of function for a recipient of
healthcare services
36. Causes of Medication Errors
Calculation errors
Overload
Shortage of staff
Illegible Handwriting
Misinterpretation of Prescription
Human Errors
Inappropriate use of Abbreviations
Oral/Verbal orders
Look alike Sound alike drugs
Wrong dosage calculation
Improper use of zeroes and decimals
Careless prescription
Missing information
Drug Product characteristics
Drug preparation errors
Prescription labeling
Work environment & personnel issues
Lack of concentration
Double check not possible
37. 1. Calculation errors
Made by
Prescribers
Pharmacists
Technicians
Nurses
Pediatric population at risk- adult formulations be diluted/manipulated for peds
Personnel with multiple years of experience are just as likely to make
mathematical errors as inexperienced
43. 4. High Alert medication errors
Only written
orders
accepted
To be
checked for
adverse
reactions
44. 5. Prescribing errors
A clinically meaningful prescribing error occurs when, as a result of prescribing decision or
prescription writing process, there is an unintentional significant reduction in the treatment
being timely and effective and Increase in the risk of harm when compared with generally
accepted practice
It includes
Incorrect prescription #Missing information
Illegible handwriting # Use of apothecary system
Drug allergy not identified #Confusion regarding concentration of products
Irrational combinations
Out of list abbreviations
Verbal orders
45. Risk factors of prescribing errors
Work environment
Workload
Communication gap within team
Physical and mental well being
Lack of knowledge
Organizational factors(inadequate training)
Low perceived importance of prescribing
An absence of self awareness
46. 6. Wrong drug & wrong route
Drug-drug interaction
Warfarin prescribed to patient already on salicylate
Duplicative therapy
Atenolol ordered for patient already taking metoprolol
No indication
Cetrizine ordered for patient with fever
Wrong route
Order of betamethazone acetate suspension ordered to be given intravenously
47. 7.Dispensing error
Any unintended deviation among the dispensed drugs on comparison with the
written medical prescription or medication order is defined as dispensing error.
The range of dispensing errors even widens in the global scenario from 0.015 to
33.5%;
4 errors per day per 250 prescriptions filled
Over 51 million dispensing errors per year
48. Most prevalent dispensing errors
Similar names and packaging of drugs (look alike Sound alike)
Wrong dose, wrong drug, or wrong patient
Dispensing incorrect medication, dosage, strength or dosage form
Failure to identify drug interations or contraindications
Dosage miscalculations
Illegible handwriting,
Negligence by the pharmacists
Other: Judgmental errors, increased workload, lack of supporting staff, frequent
interruptions, and inadequate time to label the drugs and counsel the patients.
49. 8.Look alike Sound alike drugs
LASA drugs are medications that look or
sound similar to each other, either by their
generic name, or brand name.
They might have similar packaging, similar-
sounding names, or similar spellings.
54. 8.Illegible handwriting
The jokes about physicians and their sloppy handwriting are age-old.
But for some people it is not funny at all.
A misread prescription can lead to mistreatment and cause death.
Causes both prescription error and dispensing error
7,000 deaths annually are attributable to sloppy handwriting.
Recently in a programme on BBC : concluded that in Tamil Nadu, only
one in five doctors in rural areas writes legible prescriptions
60. 10.Drug concentration
Failure to include concentration in prescription can result in wrong
dose being dispensed
E.g.
•Amoxicillin suspension half tsp (2.5ml) TID
•Concentration??
1 amp or 1 vial or 1 cap UNCLEAR
Order for one vial of magnesium sulphate
•2ml vial (8mEq)
•20 ml vial (16mEq)
•10 ml vial of 50% concentration (40mEq)
62. 13. Communication failure
Failures during the process of patient management
Includes illegible handwriting, incomplete prescribing
order, vague instructions, prescription not recognized
& unknown prescriber
Common communication errors
Common errors include ‘g’ mistaken for ‘mg’
4 mistaken for ‘U’
Decimal point (.1 read as 1)
65. 15. Administration errors
Medication administration error (MAE) is defined as “any difference between what the
patient received or was supposed to receive and what the prescriber intended in the
original order”
It is risk areas of nursing practice while administering drugs
Majority of these errors involved either dose omissions (42%) or wrong time
administration (50 %)
MAE has a significant impact on morbidity, mortality, adverse drug event, and increased
length of hospital stay.
Thus, it increases costs to clinicians and healthcare systems
66. Administration error
Incorrect administration techniques
SC administered too deep
Instilling eye drops in wrong eye
IM injection at wrong site
It involves wrong patient, wrong route of adm.,
wrong drug, wrong dose, wrong method, wrong time.
67. Causes of administration errors
Lack of knowledge on drug
preparation, administration
Fail to check 5 R’s
Poor lighting
Wrong calculations to determine
correct dose
Noise and interruptions
69. 17. Transcription error
Transcription error is a process of making an identical copy of prescription in the
medical records. Error occurs during this process is known as transcription error.
An error that occurs during transcription of physicians order to the medication
administrative record (MAR)
E.g. orders transcribed to wrong patient, wrong drug, wrong dose, wrong schedule
Contributing factors:
Incomplete or illegible nurse handwriting
Use of abbreviations
Lack of familiarity with drug names
70. 18. Wrong time error
Wrong-time medication administration error (WTMAE) is a high risk to patient
safety.
It can result in severe harm, death or fatal consequences
Standardized administration time to be followed
Acceptable interval surrounding scheduled timing
WT errors are “dose administered 60 minutes before
or after scheduled time”
71. Example for wrong time administration
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During the
admission process in the early evening, the surgical resident restarted his maintenance
home medications, including oral dofetilide (an antiarrhythmic agent) taken every 12
hours. In the electronic health record, drugs ordered for "q12 hour" dosing are scheduled
for 6 AM and 6 PM by default. The overnight nurse saw that the morning dose was
scheduled to be given at 6 AM, but the patient was scheduled to leave for the operating
room before 6 AM, so she gave the dose early, at 4 AM. During his preoperative
assessment at around 6 AM, the patient was noted to have severe QTc prolongation on
his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal
arrhythmia. Considering the acute ECG changes (prior QTc intervals were normal), surgery
was canceled and the electrophysiology service was consulted.
72. 19.Deteriorated drug error
The drug to be given to patient has been unchecked or improperly
stored and deteriorated prematurely at appropriate place leading to
deteriorated drug error
Monitoring of expiry dates become essential
Refrigerated drugs being stored at room temperature or freezer
For example, administering insulin that has been frozen.
74. 21. Monitoring error
Failing to monitor the health status of the patient prior or post drug
administration
Inadequate drug therapy review
Ordering serum drug level tests and not reviewing test results
Prescribing antihypertensive drugs and failing to monitor blood pressure
Giving antipyretics and not assessing temperature
Administering Digoxin and not monitoring pulse/ heart rate
79. Summary
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 descibed 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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