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Title: medications


1
Chapter 12
Medication Safety
2
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 errorreporting
    systems available

3
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

4
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

5
Medical Errors
  • Pharmacy technicians should
  • be constantly on the lookout for possible
    sources of errors
  • adopt patient safetyoriented work practices
  • take steps to protect the safety of patients
  • become an important barrier against an adverse
    patient outcome

6
Discussion
What are some examples of medical errors?
Edited by Dr. Ryan Lambert-Bellacov
7
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
8
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

9
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 patients health

Edited by Dr. Ryan Lambert-Bellacov, chiropractor
for Back in the Game in West Linn, OR
10
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
11
Healthcare Professionals 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

12
Healthcare Professionals Responsibility
Safety Note
The only acceptable level of medication errors
is zero.
Edited by Dr. Ryan Lambert-Bellacov
13
Healthcare Professionals 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

14
Healthcare Professionals 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

15
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

16
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
17
Healthcare Professionals Responsibility
Safety Note
If information is missing from a medication
order, never assume. Obtain the missing
information from the prescriber.
Edited by Dr. Ryan Lambert-Bellacov
18
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

19
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
20
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

21
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

22
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
23
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

24
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

25
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
26
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

27
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

28
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

29
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
30
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

31
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

32
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 persons attention,
    preventing the person from detecting the error or
    causing an error to be made

33
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

34
Root Cause Analysis of Medication Errors
Safety Note
  • Maintaining focused attention when filling
    prescriptions is important to avoid errors.

Edited by Dr. Ryan Lambert-Bellacov
35
Discussion
What are some ways to reduce each category of
error?
36
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.
37
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

38
Prescription-Filling Process in Community and
Hospital Pharmacy Practice
  • In the hospital setting medications pass through
    an extra set of handsthe nursesbefore 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

39
Prescription-Filling Process in Community and
Hospital Pharmacy Practice
Safety Note
Each person who participates in the filling
process has the opportunity to catch and correct
a medication error.
Edited by Dr. Ryan Lambert-Bellacov
40
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

41
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

42
Prescription-Filling Process
Safety Note
Careful review of the prescription or order is
very important.
Edited by Dr. Ryan Lambert-Bellacov
43
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

44
Prescription-Filling Process
Safety Note
Outdated prescriptions should not be filled.
Edited by Dr. Ryan Lambert-Bellacov
45
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

46
Prescription-Filling Process
Safety Note
A prescribers signature is required for a
prescription to be considered valid.
Edited by Dr. Ryan Lambert-Bellacov
47
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
48
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
49
Prescription-Filling Process Step 1
Edited by Dr. Ryan Lambert-Bellacov
50
Prescription-Filling Process
Safety Note
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
51
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
52
Prescription-Filling Process
Safety Note
Check the patient profile for existing allergies
or possible drug interactions.
Edited by Dr. Ryan Lambert-Bellacov
53
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
54
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
55
Prescription-Filling Process
Safety Note
Prescriptions that contain unapproved
error-causing abbreviations should be confirmed
with the prescriber.
Edited by Dr. Ryan Lambert-Bellacov
56
Prescription-Filling Process
Safety Note
Confirm that information entered into the
computer matches the original prescription.
Edited by Dr. Ryan Lambert-Bellacov
57
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?

58
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 manufacturers
    drug product from the storage shelf
  • use NDC numbers as a cross-check

59
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
60
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

61
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 patients
    prescription
  • cleaning the counting tray with alcohol after
    each drug is dispensed is recommended

62
Prescription-Filling Process
Safety Note
When compounding, do not allow interruptions and
prepare products one at a time.
Edited by Dr. Ryan Lambert-Bellacov
63
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

64
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

65
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 technicians 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?

66
Prescription-Filling Process
Safety Note
The pharmacist must always check the technicians
work.
Edited by Dr. Ryan Lambert-Bellacov
67
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 patients medications
    together and separate from other patients

68
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

69
Prescription-Filling Process
Safety Note
Pharmacy technicians cannot instruct patients. If
a technician suspects that a patient requires
instruction, then the technician should alert the
pharmacist.
70
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

71
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

72
Discussion
What information should be checked at each step
of the prescription fill process?
73
Discussion
What information should be checked at each step
of the prescription fill process? Answer
Patient identity, medication dose and form,
directions for use
74
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

75
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

76
Medication Error Prevention
Safety Note
Incorrect drug identification is the most common
error in dispensing or administration.
Edited by Dr. Ryan Lambert-Bellacov
77
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

78
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

79
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

80
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

81
Patient Education
  • Patients should understand ten key pieces of
    information about every medication
  • what the brand and generic names are
  • what the medication looks like
  • why they are taking the medication, and how long
    they will have to take it
  • how much to take, how often, and the best time or
    circumstances to take a medication
  • what to do if they miss a dose

Edited by Dr. Ryan Lambert-Bellacov
82
Patient Education
  • medications or foods which interact with what
    they are taking
  • whether new medication is in addition to or
    replaces medication currently taken
  • common side effects and what to do about them
  • special precautions for each particular drug
    therapy
  • where and how to store the medication

83
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

84
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
85
Innovations to Promote Safety
  • In hospital pharmacy, integrated computerized
    filling systems allow institutions to
  • improve efficiency
  • redirect resources

86
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 McKessons technologies
87
Discussion
What can a pharmacy technician do to prevent
medication errors?
88
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.
89
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

90
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

91
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

92
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

93
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

94
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 errorreporting
    system

Learn more about the Joint Commission
International Center for Patient Safety
95
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
96
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

97
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
98
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

99
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

100
Food and Drug Administration
  • The FDA provides an adverse event reporting form

Get an adverse event reporting form
101
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
102
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

103
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

104
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

105
Discussion
Why is the most effective error-reporting
systems, anonymous or no-fault?
106
Discussion
Why is the most effective error-reporting
systems, anonymous or no-fault? Answer Fear of
punishment may be a deterrent to
error-reporting.
107
Discussion
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