St Mary s Paddington, London 1
Medication Safety Health Care Professional s Role in Avoiding Medication Errors Describe the consequences of medication errors on the health care system. Recognize the leading causes of medication errors. List the strategies to reduce or eliminate medication errors. Communicate medication safety concerns efficiently within the health care team. 2
Packaging for a Rowenta iron: Do not iron clothes on body. Hair Dryer Do not use in shower. Portable stroller Caution: Remove infant before folding for storage. Container of lighter fluid WARNING: Contents flammable! 3
Death Death Emily Jerry Age 2 4
Death Emily Jerry Age 2 Newborn deaths from heparin overdose (Dennis Quaid s twins) Death Emily Jerry Age 2 Newborn deaths from heparin overdose (Dennis Quaid s twins) Benzathine Penicillin 5
Death Emily Jerry Age 2 Newborn deaths from heparin overdose (Dennis Quaid s twins) Benzathine Penicillin Baby in Nevada killed with Zinc Death Emily Jerry Age 2 Newborn deaths from heparin overdose (Dennis Quaid s twins) Benzathine Penicillin Baby in Nevada killed with Zinc IV administration of oral nimodipine 6
1.5 million patients are harmed each year by medication errors. 19 deaths per day Preventing Medication Errors 2006, Institute Of Medicine In hospitals 5% of patients experience a medication error each hospital experiences a medication error that adversely affects patient care outcomes every 19 days Cost Medication errors result in 3.5 billion dollars in additional hospitalization costs One ADE adds more than $2,000 on average to cost of hospitalization Extended hospital stay 4 fold Medicare does not pay for preventable medical errors 7
Recognize the leading causes of medication errors Leading causes of fatal medication errors 41% improper dose 16% wrong drug 16% wrong route Non fatal errors usually wrong drug High risk groups elderly and pediatric List the strategies to reduce or eliminate medication errors. 8
List the strategies to reduce or eliminate medication errors. FDA, Joint Commission, ISMP, CDC, NCC MERP List the strategies to reduce or eliminate medication errors. FDA, Joint Commission, ISMP, CDC, NCC MERP Abbreviations in drug names (Mg S04) and directions (qid) also leading zeros 0.5mg, 5.0mg Handwriting, transcription errors 9
List the strategies to reduce or eliminate medication errors. FDA, Joint Commission, ISMP, CDC, NCC MERP Abbreviations in drug names (Mg S04) and directions (qid) also leading zeros 0.5mg, 5.0mg Handwriting, transcription errors Electronic prescribing! List the strategies to reduce or eliminate medication errors. Pyxis machines Bar coding scanning High Alert medications CINCH Standard concentrations Warning labels SALA drugs (sound alike/look alike) Tall man lettering prednisone, prednisolone hyroxyzine, hydralazine 10
Communicate medication safety concerns efficiently within the health care team. Culture of safety Communicate medication safety concerns efficiently within the health care team. Culture of safety Eg JUST Culture Human error -inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. At-risk behavior behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. Reckless behavior -behavioral choice to consciously disregard a substantial and unjustifiable risk. 11
Communicate medication safety concerns efficiently within the health care team. Medication Incident reporting even if near miss USP and ISMP have online and telephone reporting Each hospital should have own Medication Incident Reporting. NO BLAME! ANONYMOUS! 12