medications by liuhongmei

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									Chapter 12
 Medication Safety
             Learning Objectives
• Understand the extent and effect of medical errors on
  patient health and safety
• Describe how and to what degree medication errors
  contribute to medical errors
• *List examples of medication errors commonly seen
  in practice settings
• Apply a systematic evaluation of opportunities for
  medication error to a pharmacy practice model
• Identify the common medication error–reporting
  systems available
                   Medical Errors
• A medical error is any circumstance, action, inaction,
  or decision related to healthcare that contributes to an
  unintended health result
• Most of what is known about medical errors comes
  from information collected in the hospital setting
   – hospital data make up only a part of a much larger picture
   – most healthcare is administered in the outpatient, office-
     based, or clinic setting
• Medical errors are difficult to define
   – possible causative circumstances are infinite
                   Medical Errors
• Medical-related lawsuits show the scope of medical
  errors in the United States
• One large government studied only medical errors
  during hospitalization
   – 44,000 to 98,000 people in the U.S. die each year as a
     result of medical errors (greater than the risk of death from
     accident, diabetes, homicide, or human HIV and AIDS)
   – multiple sources for potential medical errors exist
               Medical Errors

• Pharmacy technicians should
  – be constantly on the ―lookout‖ for possible sources of
    errors
  – adopt patient safety–oriented work practices
  – take steps to protect the safety of patients
  – become an important barrier against an adverse patient
    outcome
                              Discussion

                What are some examples of medical errors?




Edited by Dr. Ryan Lambert-Bellacov
              Discussion

What are some examples of medical errors?

Answer: Lab tests drawn at the wrong time
(inaccurate results), major surgical errors ending
in injury or death
               Medication Errors

• A medication error is a medical error in which the
  source of error or harm includes a medication
• Like medical errors
   – medication errors have no specific definition because
     the possible causes can be endless
   – information on the effect of medication errors comes
     mostly from studies done in the hospital setting
• Medication-related deaths are estimated at about
  7,000 each year
                                                    Medication Errors

     • Fewer studies of medication errors in community
       practice exist
               – an estimated 1.7% of all prescriptions dispensed in a
                 community practice setting contain a medication error
                 (4 of every 250 prescriptions)


     • Not all medication errors result in harm to a patient
               – 65% of the medication errors detected had a meaningful
                 effect on the patient’s health


Edited by Dr. Ryan Lambert-Bellacov, chiropractor for Back in the Game in West Linn, OR
                Medication Errors
• Measuring results of medication errors
   – lost lives
   – disabled patients
   – time lost from work or school


• cost to the healthcare system
   – billions of dollars             – physician visits
   – additional hospitalizations     – emergency room visits
   – admissions to long-term care    – continuation of disease
Healthcare Professional’s Responsibility
• Working in healthcare means making a commitment
  to ―first do no harm‖
• The profession of pharmacy exists to safeguard the
  health of the public
• Healthcare must focus on treating the patient
   – to the best possible outcome
   – by the safest possible means
• No ―acceptable‖ level of medication error exists
   – effect of a potential medication error on the patient cannot
     be predicted
   – each step in fulfilling medication orders should be reviewed
     with a 100% error-free goal
  Healthcare Professional’s Responsibility



         The only acceptable level of medication errors
         is zero.




Edited by Dr. Ryan Lambert-Bellacov
Healthcare Professional’s Responsibility
 • Pharmacists are responsible for the accuracy of the
   medication-filling process
    – technicians can assist in ensuring safety
 • Pharmacists and pharmacy technicians can work
   together to create a net of safety
 • Proper packaging and instruction on medication
   use
    – facilitates correct administration by a patient
Healthcare Professional’s Responsibility
• Technicians can identify potential patient sources of
  medication error
   – careful listening and observation during a patient or medical
     staff interaction
   – notifying the pharmacist


• Technicians make a significant contribution to patient
  safety
   – constant surveillance for potential sources of medication
     error
 Tips for Reducing Medication Errors
• Always keep the prescription and the label together
• Know common look-alike and sound-alike drugs
• Keep dangerous or high-alert medications in a
  separate storage area
• Always question bad handwriting
• Prescriptions/orders should be correctly spelled with
  drug name, strength, appropriate dosing, quantity or
  duration of therapy, dose form, and route
• Use the metric system
         Tips for Reducing Medication Errors
   •       Question uncommon abbreviations
   •       Be aware of insulin mistakes
   •       Keep the work area clean and uncluttered
   •       Verify information
   •       Labels should always be compared with the original
           prescription by at least two people




Edited by Dr. Ryan Lambert-Bellacov, chiropractor for Back in the Game in West Linn, OR
              Healthcare Professional’s
                   Responsibility



          If information is missing from a medication
          order, never assume. Obtain the missing
          information from the prescriber.




Edited by Dr. Ryan Lambert-Bellacov
Tips for Reducing Medication Errors:
            Pharmacists
• Check prescriptions in a timely manner
• Initial all checked prescriptions
• Visually check the product in the bottle
• Cross-reference prescription information with other
  validating sources
• Encourage documentation of all medication use
• Document all clarifications on orders
• Maintain open lines of communication with patients,
  healthcare providers, and caregivers
    Tips for Reducing Medication Errors:
                Technicians

    •   Use the triple-check system
    •   Regularly review work habits
    •   Verify information with the patient or caregiver
    •   Observe and listen
    •   Keep your work area free of clutter




Edited by Dr. Ryan Lambert-Bellacov
               Patient Response
• Most patients have the intended therapeutic
  response expected from the medication

• Unique physical and social circumstances make it
  impossible to predict which
   – medication errors may result in no substantial harm
   – may result in death
  Physiological Causes of Medication
                Errors
• Each patient has a unique response to medication
   – genetically unique
   – speed at which medications are removed from
     body varies

• Even a problem caught and corrected before harm
  occurs is still considered a medication error
      Social Causes of Medication Errors
    • Outpatients can contribute to medication errors
      through incorrect administration

    • Social causes of error include:
        – failure to follow medication therapy instructions because
          of cost
        – noncompliance
        – failure to receive therapy
        – misunderstanding instructions (language barriers)



Edited by Dr. Ryan Lambert-Bellacov
  Social Causes of Medication Errors

• Patients can contribute to medication errors by
   – forgetting to take a dose or doses
   – taking too many doses
   – dosing at the wrong time
   – not getting a prescription filled or refilled in a timely
     manner
   – not following directions on dose administration
   – terminating the drug regimen too soon
 Social Causes of Medication Errors

• Social causes may result in an adverse drug
  reaction, or a toxic dose

• Over 50% of patients on necessary long-term
  medication are no longer taking their medication
  after 1 year

• All of these social circumstances would be
  considered medication errors
         Categories of Medication Errors

     • Possible causes of a medication error are
       numerous

     • Categorizing errors into types aids in identification
       and prevention of possible causes

     • Categories focus on grouping errors under a set of
       common definitions


Edited by Dr. Ryan Lambert-Bellacov
    Categories of Medication Errors
• omission error: a prescribed dose is not given
• wrong dose error: a dose is either above or below the
  correct dose by more than 5%
• extra dose error: a patient receives more doses than
  were prescribed by the physician
• wrong dose form error: dose form or formulation that
  is not the accepted interpretation of the physician order
• wrong time error: drug is given 30 minutes or more
  before or after it was prescribed
   Categories of Medication Errors
• Errors can be classified by what causes the failure
  of the desired result

• Errors can be categorized within three basic
  definitions of failure:
   – human failure
   – technical failure
   – organizational failure
    Categories of Medication Errors
• Human failure is a failure that occurs at an
  individual level
   – pulling a medication bottle from the shelf based on
     memory, without cross-referencing the bottle label with
     the medication order/prescription
   – errors made by the patient such as non-compliance to
     prescribed drug therapy
• Technical failure is a failure resulting from
  location or equipment
   – incorrect reconstitution of a medication because of a
     malfunction of a sterile-water dispenser
   – failure to properly operate automated equipment
    Categories of Medication Errors
• Organizational failure is a failure because of
  organizational rules, policies, or procedures
   – a policy or rule requiring preparing drugs in an
     inappropriate setting




   Visit the Veterans Administration (VA) National Center for Patient Safety
   Web site for a glossary of patient safety terms
  Root Cause Analysis of Medication
               Errors
• Root cause analysis is a logical and systematic
  process used to help identify what, how, and why
  something happened to prevent reoccurrence

• With basic principles of root cause analysis, any
  person can
   – examine his or her own work flow to determine the
     opportunities for potential error
   – determine what type of failure the potential error may be
   – create a list of specific potential causes
  Root Cause Analysis of Medication
               Errors

• Identifying specific potential causes allows a person
  to take specific actions to prevent the potential error
• Actions taken improve the quality of work being done
• Common causes of medication error by handlers and
  preparers include:
   – assumption error
   – selection error
   – capture error
  Root Cause Analysis of Medication
               Errors
• assumption error: an essential piece of information
  cannot be verified and is guessed or presumed
   – misreading an abbreviation on a prescription
• selection error: two or more options exist, and the
  wrong option is chosen
   – using a look-alike or sound-alike drug instead of prescribed
     drug
• capture error: focus on a task is diverted elsewhere
  and an error goes undetected
   – something captures the person’s attention, preventing the
     person from detecting the error or causing an error to be
     made
  Root Cause Analysis of Medication
               Errors

• To prevent capture errors
   – determine when and where in the prescription-filling
     process it is safe to allow focus on a task to be diverted


• Knowing when and when not to allow interruptions is
  important in individual safety practices
      Root Cause Analysis of Medication
                   Errors


            Maintaining focused attention when filling
            prescriptions is important to avoid errors.




Edited by Dr. Ryan Lambert-Bellacov
            Discussion

What are some ways to reduce each category
of error?
              Discussion

What are some ways to reduce each category
of error?

Answer: Assumption errors may be avoided by
verifying all information instead of guessing;
capture errors may be avoided by reviewing work
habits and determining when interruptions are or
are not appropriate; selection errors may be
avoided by cross-referencing products chosen
with the order/prescription and the shelf label.
Prescription-Filling Process in Community
     and Hospital Pharmacy Practice

• Review for potential causes of medication error
  begins with outlining work tasks in a step-by-step
  manner

• Each step in this process can be a
   – source of medication error
   – place where pharmacy personnel can correct a
     medication error
Prescription-Filling Process in Community
     and Hospital Pharmacy Practice
• In the hospital setting medications pass through an
  extra set of hands—the nurse’s—before reaching the
  patient
   – an extra opportunity to prevent medication errors
   – an additional source of potential medication errors
• Each step should be reviewed to determine what
  information is necessary to complete the step
   – what resources can be used to verify the information
   – what errors might result if information is missed or
     verification is not performed
    Prescription-Filling Process in Community
         and Hospital Pharmacy Practice



           Each person who participates in the filling
           process has the opportunity to catch and correct
           a medication error.




Edited by Dr. Ryan Lambert-Bellacov
       Prescription-Filling Process
Think of each step in three parts:
• information that must be obtained or checked

• resources that can be used to verify information

• potential medication errors that would result from a
  failure to obtain or check the necessary information
  using the appropriate resources
        Prescription-Filling Process
  Step 1: Receive Prescription and Review
                Patient Profile

• Initial check of all key pieces of information is vital
   – thoughtful and thorough initial review reduces the chances
     that an unidentified error will continue through the filling
     process
• Legibility: Can you read and understand it?
   – any unclear information should be clarified before any
     further action is taken
            Prescription-Filling Process



          Careful review of the prescription or order is
          very important.




Edited by Dr. Ryan Lambert-Bellacov
        Prescription-Filling Process
                   Step 1
• Validity: Is the prescription valid?
   – requirements may vary from state to state
      • every technician should be familiar with the definition of valid
        prescription for the state in which he or she practice

   – does it contain all the required information to be valid?
      • a prescription is valid for up to 1 year (less in some cases)
        from the date of its writing

   – if not valid, the prescription should not be filled
            Prescription-Filling Process



          Outdated prescriptions should not be filled.




Edited by Dr. Ryan Lambert-Bellacov
        Prescription-Filling Process
                   Step 1
• Patient information: Is there enough detail to ensure
  that unique individuals can be pinpointed?
   – full names, addresses, dates of birth, and phone numbers
     give multiple points to cross-reference and separates patients
   – date of birth and allergies should always be included
• Physician information: Is it sufficient to determine that
  a licensed prescriber wrote the prescription?
   – contact information should be included
   – no prescription or medication order is valid without the
     signature of the prescriber
            Prescription-Filling Process



           A prescriber’s signature is required for a
           prescription to be considered valid.




Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process
                       Step 1

     • Medication information should include:

           – drug name                – route of administration
           – strength                 – refills or length of therapy
           – dose                     – directions for use
           – dose form                – dosing schedule




Edited by Dr. Ryan Lambert-Bellacov
              Prescription-Filling Process
                         Step 1
    • Prescribing errors include:
       –   poor handwriting
       –   using nonstandard abbreviations
       –   confusing look-alike and sound-alike drug names
       –   wrong drug
       –   using ―as directed‖ instructions




Edited by Dr. Ryan Lambert-Bellacov
             Prescription-Filling Process
                        Step 1




Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process



           A leading zero should precede values less than
           one, but a zero should not follow a decimal if
           the value is a whole number. A tenfold error
           occurs if the decimal point is not detected.




Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process
                       Step 1
  • Opportunities for medication errors increase with the
    number of medications a patient takes
      – common with many older patients


  • Profile review for every prescription should include:
      – check for existing allergies and multiple drug therapy
      – check for drug interactions or duplication of therapy




Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process



         Check the patient profile for existing allergies
         or possible drug interactions.




Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process
      Step 2: Enter Prescription into Computer

   • Accuracy in this function can make the difference
     between
      – a patient receiving a correct and appropriate medication
                                or
      – a prescription that could cause the patient serious harm or
        death




Edited by Dr. Ryan Lambert-Bellacov
         Prescription-Filling Process
                    Step 2
• Concentration and focus are very important
   – prescription information should be compared with choices
     from the computer menu
• Does the form or formulation match the route of
  administration?
• Compare each data element of the completed entry
  with the same data elements on the original
  prescription

   Check the Institute for Safe Medication Practices Web site for dangerous
   abbreviations or dose designations
            Prescription-Filling Process



        Prescriptions that contain unapproved error-causing
        abbreviations should be confirmed with the
        prescriber.




Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process



        Confirm that information entered into the computer
        matches the original prescription.




Edited by Dr. Ryan Lambert-Bellacov
        Prescription-Filling Process
     Step 3: Generate Prescription Label

• Check for the accuracy of any technology in the
  prescription filling process
• Cross-check the label output from the computer with
  the original prescription
   – make sure that a typing error or inherent program
     malfunction did not alter the information
   – Is the correct patient name on the label?
   – Are the drug, dose, concentration, and route information
     identical to the original prescription?
       Prescription-Filling Process
          Step 4: Retrieve Medication

• Products can contribute to errors with
   – look-alike labels
   – similarities in brand or generic names
   – similar pill shapes or colors
• Use NDC numbers, drug names, and other
  information to verify selection of the correct product
   – use both the original prescription and the generated label
     when selecting a manufacturer’s drug product from the
     storage shelf
   – use NDC numbers as a cross-check
            Prescription-Filling Process
                       Step 4
    • Accidental substitution of one drug or ingredient for
      another is one of the most serious events that can
      occur in pharmacy practice
    • Most pharmacy practices possess a computer-based
      ―pill identification‖ program and use a shelf labeling
      system to organize inventory
       – visual comparison of the medication dispensed with a
         picture of the medication




Edited by Dr. Ryan Lambert-Bellacov
       Prescription-Filling Process
    Step 5: Fill or Compound Prescription

• Calculation and substitution errors are sources of
  medication errors
   – write out the calculation and have a second person check
     the answer


• Take care when reading labels and preparing
  compounded products
        Prescription-Filling Process
                   Step 5
• Medication errors may occur when
   – using more than one container of product
   – preparing more than one product at a time
   – distractions and interruptions intrude
• All equipment should be maintained, cleaned, and
  calibrated on a regular basis
   – potential for serious harm to a patient if the residue or dust
     from an allergy-causing medication contaminates the
     patient’s prescription
   – cleaning the counting tray with alcohol after each drug is
     dispensed is recommended
            Prescription-Filling Process



       When compounding, do not allow interruptions and
       prepare products one at a time.




Edited by Dr. Ryan Lambert-Bellacov
       Prescription-Filling Process
                  Step 5
• Caution and warning labels on a prescription
  container serve as reminders to patients about drug
  handling or administration

• Computerized systems generate caution and
  warning labels with the prescription label
   – coordinate with patient information handouts
   – should be included with prescription labeling
        Prescription-Filling Process
 Step 6: Review and Approve Prescription

• The pharmacist must be the one to review and
  approve the prescription
   – verifies the quality and integrity of the end product


• Providing the pharmacist with all resources that are
  useful to ensure accurate verification is vital to
  patient safety
        Prescription-Filling Process
                   Step 6
• Determine what information and resources are
  important
   – ask whether the information provided with the medication
     filled allows the pharmacist to retrace the technician’s steps
     in filling the prescription
   – Can the pharmacist determine whether prescription is valid,
     patient information is accurate, and medication correctly
     prepared from information provided with the finished
     product?
            Prescription-Filling Process



       The pharmacist must always check the technician’s
       work.




Edited by Dr. Ryan Lambert-Bellacov
        Prescription-Filling Process
    Step 7: Store Completed Prescription
• Ensuring the integrity of medication is an important
  part of medication safety
• Many medications are sensitive to light, humidity, or
  temperature
   – failure to properly store medications may result in loss of
     drug potency or effect
   – improper storage of a drug may result in a degraded product
     that causes serious harm
• Well-organized and clearly labeled storage systems
  help to keep a patient’s medications together and
  separate from other patients
      Prescription-Filling Process
  Step 8: Deliver Medication to Patient

• In community pharmacies, medication is directly
  received by the patient
• In hospitals, medications are administered and
  monitored by someone other than the patient
• Verify prescription information against knowledge
  and expectations of patient or caregiver
• Comparing completed prescription against
  information provided by patient allows a final
  opportunity to capture potential errors
    Prescription-Filling Process



Pharmacy technicians cannot instruct patients. If a
technician suspects that a patient requires
instruction, then the technician should alert the
pharmacist.
        Prescription-Filling Process
                   Step 8
• In hospitals, medication is ultimately received by the
  nurse
   – an additional person to confirm accuracy and
     appropriateness
   – creates opportunity for a medication error


• Notify the nurse that a newly prescribed medication
  has been delivered to the floor
       Prescription-Filling Process
                  Step 8
• Ask whether
   – the nurse knows about the medication
   – medications delivered were all they were expecting


• If a drug is missing from the drug therapy
  combination, treatment is incomplete
   – incomplete therapy is also a medication error
             Discussion
What information should be checked at each
step of the prescription fill process?
              Discussion
What information should be checked at each
step of the prescription fill process?

Answer: Patient identity, medication dose and
form, directions for use
       Medication Error Prevention

• Preventing medication errors means
   – carefully examining potential points of failure
   – using available resources to verify information given or
     decisions made


• Drug identification is the most common error in
  dispensing and administration
        Medication Error Prevention
• Pharmacy technicians ―own‖ a substantial portion of
  the prescription-filling process
   – first to examine a prescription submitted for filling
   – last to handle medication before it reaches the patient
• Pharmacy technicians have the most opportunities to
  prevent medication errors
   – can identify potential sources of error beyond prescription
     dispensing
   – interact with a patient or nurse when a prescription comes in
     or goes out of the pharmacy
           Medication Error Prevention



       Incorrect drug identification is the most common
       error in dispensing or administration.




Edited by Dr. Ryan Lambert-Bellacov
        Medication Error Prevention
• Many medication errors occur during prescribing
  and administration
• Prescribers are responsible for ensuring the ―five
  Rs‖ or five rights
   – the right drug
   – for the right patient
   – at the right strength
   – given by the right route
   – administered at the right time
           Medication Error Prevention

• Pharmacy practice overlays physician responsibility
  and thereby facilitates patient safety and error
  prevention by processes to verify the following:
   –   the correct patient is being given the medications
   –   other associated medications are correct
   –   correct drug is dispensed
   –   correct dose is prepared
   –   correct route of administration is indicated
   –   appropriate dose form is prepared
   –   correct administration times
   –   correct conditions for administration are met
                Patient Education
• Patients and caregivers must have necessary
  knowledge to administer, handle, and support safe
  medication use
• Pharmacy technicians can encourage patients to
   – ask questions
   – relay complete medical and allergy history
   – check medications for information on administration
• Pharmacy technicians should be actively involved in
  monitoring for potential errors
               Patient Education

• Pharmacy technicians cannot instruct patients but
  can
   – encourage patients to become informed about their
     conditions
   – encourage patients to ask the pharmacist questions
     about prescribed medications
   – assist patients in becoming more informed
   – empower them to be advocates for their own safety and
     health
                    Patient Education
       Patients should understand ten key pieces of
       information about every medication:
      1) what the brand and generic names are
      2) what the medication looks like
      3) why they are taking the medication, and how long they
         will have to take it
      4) how much to take, how often, and the best time or
         circumstances to take a medication
      5) what to do if they miss a dose



Edited by Dr. Ryan Lambert-Bellacov
             Patient Education

6) medications or foods which interact with what they are
    taking
7) whether new medication is in addition to or replaces
    medication currently taken
8) common side effects and what to do about them
9) special precautions for each particular drug therapy
10) where and how to store the medication
    Innovations to Promote Safety

• The physical pharmacy work setting can have a
  major contribution to the overall safety of any
  work environment
• Automate and bar code all fill procedures
• Maintain a clean, organized, orderly work area
• Provide adequate storage areas
• Encourage prescribers to use common
  terminology and only safe abbreviations
• Provide adequate computer applications and
  hardware
     Innovations to Promote Safety
• Innovations can minimize possibility of errors
• In community pharmacy, redesigned packaging helps
  patients take medication safely
  – Target ClearRx packaging helps patients manage their
    medications
      • colored rings help patients identify medications intended for
        each family member
      • clear, easy-to-read label for patient administration
        instructions and cautions
      • includes a pullout patient information card or printout

  Learn more about the Target label design
      Innovations to Promote Safety
• In hospital pharmacy, integrated computerized filling
  systems allow institutions to
   – improve efficiency
   – redirect resources
       Innovations to Promote Safety

• When a pharmacist is actively involved in medication
  decisions, safety and outcomes for patients are
  substantially improved
   – technologic advances empower the pharmacy technician staff
     to become more productive, and as a result, pharmacists are
     freed to become more involved in patient care




    Learn more about McKesson’s technologies
              Discussion

What can a pharmacy technician do to prevent
medication errors?
                Discussion

What can a pharmacy technician do to prevent
medication errors?

Answer: A pharmacy technician is in the ideal
position to identify potential sources of error,
encourage patient education, and monitor for
problems.
 Medication Error and Adverse Drug
   Reaction Reporting Systems
• The first step in prevention of medication errors is
  collection of information
• Fear of punishment is a concern with errors
   – people may decide not to report an error at all
   – allows the same error to occur again and again
• Anonymous (no-fault) reporting systems have been
  established
   – focus on fixing the problem, not fixing the blame
         State Boards of Pharmacy
• More than 20 states have mandatory error-
  reporting systems
   – most state officials admit medical errors are still under-
     reported mostly because of fear of punishment


• Some states have worked to reduce the fear of
  reporting
   – allow pharmacists to document errors and error-prone
     systems without worry of punishment
   – most boards of pharmacy will not punish pharmacists
     for errors
         State Boards of Pharmacy
• Pharmacy technicians are an integral part of the
  error identification, documentation, and prevention
  process

• The final and most important piece of medication
  error reporting is informing the patient that a
  medication error has taken place
   – commonly the task of the pharmacist
         State Boards of Pharmacy
• The circumstances leading to the error should be
  explained completely and honestly
• Patients should understand
   – the nature of the error
   – what if any effects the error will have
   – how they can become actively involved in preventing
     errors in the future
• People are more likely to forgive an honest error
Joint Commission on Accreditation for
       Healthcare Organizations
• Organizations can create a centralized point through
  which all members may channel error information
  safely
• The Sentinel Event Policy was created by the Joint
  Commission on Accreditation for Healthcare
  Organizations (JCAHO) in 1996
• A sentinel event is an unexpected occurrence
  involving death or serious physical or psychologic
  injury
Joint Commission on Accreditation for
       Healthcare Organizations
• When a sentinel event is reported, the organization is
  expected to
   – analyze the cause of the error (perform a root cause
     analysis)
   – take action to correct the cause
   – monitor the changes made
   – determine whether the cause of the error is eliminated
• Accreditation of hospitals depends on demonstrating
  an effective active error–reporting system
  Learn more about the Joint Commission International Center for Patient
  Safety
            United States Pharmacopeia
     • The United States Pharmacopeia (USP) supports
       two types of reporting systems for the collection
       of medical errors and adverse drug reactions
        – Medication Errors Reporting Program
        – MEDMARX




Edited by Dr. Ryan Lambert-Bellacov
      United States Pharmacopeia

• The Medication Errors Reporting Program is
  designed to allow healthcare professionals to
  report medication errors directly

• MEDMARX is an internet-based program for use
  by hospitals and healthcare systems for
  documenting, tracking, and trending medication
  errors
       United States Pharmacopeia

• Both USP programs support research into
  medication-related adverse events
  – use the information to develop medication-specific
    patient safety initiatives




  Learn about the Medication Errors Reporting Program and MEDMARX
    Food and Drug Administration

• Food and Drug Administration (FDA) is the
  government body responsible for approving the
  safety of medications and medical devices

• MedWatch is an FDA reporting system for
  adverse events resulting from medications and
  medical devices
     Food and Drug Administration
• FDA uses MedWatch information to track
  unrecognized problems or issues not apparent when
  the medication or medical device was approved

• A problem or potential for error does not mean the
  product will be removed from the market
   – often safety risks may be reduced or eliminated by
      • improving of prescribing information
      • education of healthcare professionals or the public
      • name change
      Food and Drug Administration

The FDA provides an
adverse event reporting
form




   Get an adverse event reporting
   form
 Institute for Safe Medication Practices
• The Institute for Safe Medication Practices (ISMP)
   – non-profit healthcare agency
   – comprised of physicians, pharmacists, and nurses
• The mission statement is
   – ―to understand the causes of medication errors and to
     provide time-critical error reduction strategies to the
     healthcare community, policy makers, and the public‖
• ISMP in concert with USP provides a confidential
  national voluntary program
   – MERP (Medication Errors Reporting Program)
                                                    Visit ISMP
Institute for Safe Medication Practices
• Errors reported through MERP include:
   –   wrong drug, strength, or dose
   –   confusion over look-alike and sound-alike drugs
   –   incorrect route of drug administration
   –   calculation or preparation errors
   –   misuse of medical equipment
   –   errors in prescribing, transcribing, dispensing, or
       monitoring medications


• Reports can be completed on-line
Institute for Safe Medication Practices
• ISMP has
  – sponsored national forums on medication errors
  – recommended addition of labeling or special hazard
    warnings on potentially toxic drugs
  – encouraged revisions in potentially dangerous
    pharmaceutical advertising
  – promoted the use of a zero prior to a decimal number
    less than 1 on drug doses
Institute for Safe Medication Practices
• ISMP is active in disseminating information to
  healthcare professionals and consumers
   – email newsletter
   – journal articles
   – videotape training exercises


• ISMP web site posts
   – FDA Safety alerts
   – ISMP Hazard Alerts
             Discussion

Why is the most effective error-reporting
systems, anonymous or no-fault?
              Discussion

Why is the most effective error-reporting
systems, anonymous or no-fault?

Answer: Fear of punishment may be a deterrent to
error-reporting.****
Back in the Game Sports Medicine
              Discussion
is a clinic dedicated to the
treatment of physical injuries to the
body. Caring for an injured body
involves more than making the
diagnosis; it's about understanding
and treating the cause to prevent
future injuries. The clinic addresses
variety of injuries to the body
whether it be from a car accident to
over-use trauma. When injuries
occur, it is no longer enough for
people to "take it easy for awhile"
or "work through it." Sports
medicine professionals like Back in
the Game offer

								
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