SlideShare ist ein Scribd-Unternehmen logo
1 von 58
Downloaden Sie, um offline zu lesen
Jabatan Farmasi
Institut Kanser Negara
MEDICATION SAFETY
 Richard Smith, who had a history of kidney disease, had been
admitted to the ICU after a dialysis session where he
experienced severe shortness of breath. The next day, July 30,
2010, he complained of an upset stomach, so the doctor
prescribed the antacid.
 The day his daughter came by to visit that morning, and found
his dad "unconscious, unresponsive and on a respirator.“
 "The nurse said my dad had coded. I said, 'He coded? When did
that happen?‘”
 The doctor told him, "I'm sorry to have to tell you this but the
nurse administered the wrong medication and sent your dad into
respiratory arrest.“
 "He said the packaging looked the same and he grabbed the
wrong package,“
 The nurse is wrongly given pancuronium instead of antacid.
UPSET STOMACH TO CODE RED
Medication Safety
MEDICATION ERROR - DEFINITION
“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.
National Coordinating Council for Medication
Error Reporting and Prevention (NCCMERP, US)
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
Healthcare is nearly
10 years behind other
industries in its efforts to
reduce errors.
Michael A. Jackson, BS Pharm, RPh
Wesley G. Reines, PharmD
“MEDICATION ERROR :
SIMPLE MISTAKE
CAN BE LETHAL”
Medication Safety Is Everyone’s Responsibilities
“PLEASE DO NO HARM”
MEDICATION ERROR:
WHY THE CONCERN?
 The impact of medication safety incidents on patient outcomes
includes increased length of stay, disability and mortality
( V i n c e n t e t a l . , 2 0 0 1 , U K )
 Medication errors are estimated to account for at least 7,000 deaths
in the United States alone every year.
Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of
Medicine; 1999, p. 1 .
 Over 770,000 patients are estimated to be injured because of
medication errors every year.
A g e n c y f o r H e a l t h R e s e a r c h a n d Q u a l i t y , 2 0 0 1
 At least 1 death occurs per day and 1.3 million people are injured
each year due to medication errors.
Food and Drug Administ rat ion (FDA), US
 Medication error is one of the most common causes of unintentional
harm in Australia which results in an estimated 80,000 hospital
admissions every year
( S e n a t o r K a y P a t t e r s o n , F e d e r a l M i n i s t e r f o r H e a l t h a n d A g e i n g A u s t r a l i a , 9 S e p t e m b e r 2 0 0 3 )
MEDICATION ERROR:
WHY THE CONCERN?
 Medication errors occur in nearly 1 out of every 5 doses given to
patients in the typical hospital.
( R e f e r e n c e : B a r k e r K N , F l y n n E A , P e p p e r G A , P h D , B a t e s D W , M i k e a l R L . M e d i c a t i o n e r r o r s o b s e r v e d i n 3 6 h e a l t h c a r e f a c i l i t i e s . A r c h
I n t e r n M e d 2 0 0 2 ; 1 6 2 : 1 8 9 7 - 1 9 0 3 . )
 One 5-year study showed that the most common types of medication
errors were a wrong dose, a wrong drug or a wrong route of
administration.
( R e f e r e n c e : P h i l l i p s J , B e a m S , B r i n k e r A , H o l q u i s t C , H o n i g P , L e e L Y , P a m e r C . R e t r o s p e c t i v e a n a l y s i s o f m o r t a l i t i e s a s s o c i a t e d w i t h
m e d i c a t i o n e r r o r s . A m J H e a l t h S y s t P h a r m . O c t 2 0 0 1 . 5 8 ( 1 9 ) ; 1 8 3 5 - 4 1 )
 Adverse medication events have been reported and are estimated to
occur at a rate of around 5% for admissions and discharges from the
typical hospital.
( R e f e r e n c e : C l a s s e n D C , P e s t o n i k S L , E v a n s R S , L l o y d J F , B u r k e J P . A d v e r s e d r u g e v e n t s i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 7 ; 2 7 7 : 3 0 1 -
3 0 6 . L a z a r o u J , P o m e r a n z B H , C o r e y P N . I n c i d e n c e o f a d v e r s e d r u g r e a c t i o n i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 8 ; 2 7 9 : 1 2 0 0 - 1 2 0 5 . )
 Several studies point to more than 50% of potential and serious
adverse events being associated with injectable medications.
(R e f e r e n c e : K a u s h a l R , B a t e s D W , L a n d r i g a n C , e t a l . M e d i c a t i o n e r r o r s a n d a d v e r s e d r u g e v e n t s i n p e d i a t r i c i n p a t i e n t s . J A M A 2 0 0 1 ;
2 8 5 : 2 1 1 4 - 2 1 2 0 . T h o m a s E J , B r e n n a n T A . I n c i d e n c e a n d t y p e s o f p r e v e n t a b l e a d v e r s e e v e n t s i n e l d e r l y p a t i e n t s : p o p u l a t i o n b a s e d r e v i e w
o f m e d i c a l r e c o r d s . B M F 2 0 0 0 ; 3 2 0 : 7 4 1 - 7 4 4 . )
MEDICATION ERROR:
WHY THE CONCERN?
 The extra medical costs of treating drug-related
injuries occurring in hospitals alone conservatively
amount to $3.5 billion a year. This estimate does not
take into account lost wages and productivity or
additional healthcare costs
" P r e v e n t i n g M e d i c a t i o n E r r o r s : Q u a l i t y C h a s m S e r i e s ” , I O M R e p o r t , J u l y 2 0 0 6
 IOM issued a report on the prevalence of medication
errors in the United States in which at least 1.5 million
Americans are injured every year by medication errors.
Martin A Makary, and Michael Daniel BMJ. 2016;353:bmj.i2139
NEWSPAPER REPORTS
WHERE CAN MEDICATION ERROR OCCUR?
Medication error may be related to professional
practice, health care products, procedures, and
systems, including prescribing, order
communication, product labeling, packaging,
and nomenclature, compounding, dispensing,
distribution, administration, education,
monitoring, and use”
Medication Safety
Prescribing Transcribing Dispensing Administering
Medication Management Processes
Errors
• Wrong Dose
• Wrong Drug
• Wrong Route/Form
• Allergy
• Drug Interaction
• Wrong Dose
• Wrong Drug
• Wrong Route
• Wrong Time
• Wrong Patient
• Wrong Dose
• Wrong Drug
• Wrong Route
• Wrong Time
• Wrong Patient
• Incorrect Labelling
• Primary Catch for
allergy, drug
interaction
• Wrong Dose
• Wrong Drug
• Wrong Route
• Wrong Time/ Omitted
• Wrong Patient
• Incorrect Labelling
MEDICATION SAFETY IS EVERYONE’S
RESPONSIBILITIES
The Pharmaceutical Services Division has always placed
emphasis on medication safety and its strategies are in line with
those of the Patient Safety Council of Malaysia
Strategies to Improve Medication Safety
Reporting & Learning Dissemination of
Information
Guidelines
Education &
Empowerment
Medication Safety
MEDICATION ERROR REPORTS
 Current medication error are reported to:
 United States Pharmacopeia
 ISMP
 Medwatch reports
 Manufacturer reports
 UK : National Reporting and Learning System (NRLS), National
Patient Safety Agency (NPSA)
 Australia : NSW Health Incident Information Management
System(IIMS), Queensland Health Clinical Incident Information
System (PRIME CI) in Queensland
 Malaysia : MERS
MEDICATION ERROR REPORTING SYSTEM
(MERS)
MEDICATION ERROR (ME) REPORTING
SYSTEM (MERS)
Purpose:
a) To obtain information on the occurrence
of medication errors
b) To maintain a database on medication
errors
c) To analyse the report
d) To propose remedial actions and monitor
the situations
e) To minimize the reoccurrence of such
errors
NUMBER OF ME REPORTS RECEIVED BY
YEAR
2572
4120
5003
6011
8422
16897
43025
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
PROCESS IN WHICH THE ERROR
OCCUR
2387
3568 3290
4017
5229
13056
139
421 1131
1433
2645
3301
44
84
407
416
398
326
2
5
41
37
31
32
0
42
134
108
119
182
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Combination
Others
Administration
Dispensing
Prescribing
Contributing
Factors of
ME
Staff
Factors
Task &
Technology
Medication
related
Work &
Environment
CONTRIBUTING FACTORS OF ME
12003,
48%
8759,
35%
3066,
12%
1106,
5%
2014
Staff Factors Work Environment
Task & Technology Medication Related
Contributing Factors No of Reports Total
Medication
Related
Look alike medication 317
1106
Look alike packaging 337
Sound alike medication 452
Staff Factors
Distraction 3455
12003
Inadequate knowledge 2369
Inexperienced personnel 6179
Task &
Technology
Failure to adhere to work procedure 1647
3066
Illegible prescription 646
Incorrect computer entry 101
Patient information/record/ unavailable/
inaccurate 507
Use of abbreviations 165
Work & Environment
Heavy workload 2566
8759
Peak hour 5492
Stock arrangements/ storage problem 260
Wrong labeling/ instruction on dispensing
envelope or bottle/ container 441
Medication Safety
ERROR-PRONE ABBREVIATION
Abbreviation Intended meaning Common Error
U Units
Mistaken as a zero or a four (4) resulting in overdose.
Also mistaken for "cc" (cubic centimeters) when
poorly written.
µg Micrograms
Mistaken for "mg" (milligrams) resulting in an
overdose.
Q.D.
Latin abbreviation for
every day
The period after the "Q" has sometimes been
mistaken for an " I, " and the drug has been given
"QID" (four times daily) rather than daily.
Q.O.D.
Latin abbreviation for
every other day
Misinterpreted as "QD" (daily) or "QID" (four times
daily). If the "O" is poorly written, it looks like a period
or "I."
ERROR-PRONE ABBREVIATION
Abbreviation Intended meaning Common Error
SC or SQ Subcutaneous
Mistaken as "SL" (sublingual) when poorly
written.
D/C
Discharge; also
discontinue
Patient's medications have been prematurely
discontinued when D/C, (intended to mean
"discharge") was misinterpreted as "discontinue,"
because it was followed by a list of drugs.
IU International Unit Mistaken as IV (intravenous) or 10(ten)
 MMF – MTF
 HCT – HCTZ – HCQ
 CBZ – CPZ
 IVIg vs Human Albumin
ERROR-PRONE ABBREVIATION
HOW TO PREVENT ERROR?
 Use generic names for drug. Avoid trade names.
 Avoid using abbreviations
 Write clear instructions
Daonil Glibenclamide
X √
MTF Metformin
X √
Gutt. CMC BD Gutt. CMC 2 drops RE BD
X √
HOW TO PREVENT ERROR?
 Use leading zero before decimal point
 Avoid trailing zero after decimal point
Avoid verbal orders
Identify patient drug allergies
.5 mg 0.5 mg
X √
5.0 mg 5 mg
X √
Medication Safety
LOOK ALIKE SOUND ALIKE MEDICATIONS
(LASA)
Medications that are:
 Visually similar in physical
appearance or packaging
 Name of the medications that have
spelling similarities
Inj. Vitamin K 1mg/ml Inj. Neostigmine Inj. Vitamin K 10mg/ml
SOUND ALIKE MEDICATIONS
 Clotrimazole – Co-trimoxazole
 Oxycontin - Oxynorm
 Dopamine - Dobutamine
 Adrenaline - Atropine
 Noradrenaline – Adrenaline
HOW TO PREVENT ERROR?
 Double checking the drug (dispensing/administering)
 (Pharmacist) Contacting the prescribers in case of
any clarification regarding the prescription
(DO NOT ASSUME)
 Becoming familiar with LASA medications
 Separating LASA medications from one another
 Using Tall Man Lettering
 Installing warning system to staff – Computer alerts
or warnings on stock bottles
SEPARATING LASA MEDICATIONS FROM ONE
ANOTHER
EXTRA CAUTIONARY LABELS
TALL MAN LETTERING
No Medication No Medication No Medication No Medication
1 ATRAcurium 13 DOBUTamine 25 LOsartan 37 PANTOprazole
2 BISOprolol 14 DOXOrubicin 26 LOVAstatin 38 PERINDOpril
3 BUPIvacaine 15 DOPamine 27 metFORMIN 39 progyLUTON
4 carBAMAZepine 16 DuphASTON 28 METOprolol 40 ProgyNOVA
5 carBIMazole 17 DuspaTALIN 29 NEostigmine 41 ProSCAR
6 cefOTAXime 18 ENALApril 30 NeuroBION 42 PROzac
7 cefTAZIDime 19 ESOMEprazole 31 NeuroNTIN 43 ROcuronium
8 cefTRIAXone 20 FORTzaar 32 niFEDipine 44 ROPIvacaine
9 chlorproMAZINE 21 gliBENclamide 33 niMODipine 45 SETRAline
10 chlorproPAMIDE 22 gliCLAzide 34 nitroGLYCERINe 46 STELLAzine
11 COzaar 23 LANSOprazole 35 nitroPRUSSIDe 47 VEcuronium
12 DAUNOrubicin 24 LIGNOcaine 36 PANcuronium 48 vinBLAStine
TALL MAN LETTERING
DISSEMINATION OF INFO
FENTANYL PATCH - HOW TO CUT
Needs to be cut DIAGONALLY
6 MCG/HR
6 MCG/HR
Only for
6mcg/hr dose
For 12mcg/hr
dose, use
25mcg/hr patch
(cut into half)
12 MCG/HR
12 MCG/HR
FENTANYL PATCH - HOW TO ADMINISTER
12 MCG/HR
DOSE HOW TO ADMINISTER
6 MCG/HR
FOR 3 DAYS
½ patch
12mcg/hr
18 MCG/HR
FOR 3 DAYS
½ patch
25mcg/hr
+ ½ patch
12mcg/hr
6mcg/hr
6mcg/hr12mcg/hr
+
 Guide On Handling Look Alike Sound Alike Medications
HIGH ALERT MEDICATIONS (HAMS)
 Drugs that bear a heightened risk of causing significant
patient harm when they are used in error.
 Although mistakes may or may not be more common
with these drugs, the consequences of an error are
clearly more devastating to patients.
Institute for Safe Medication Practice (ISMP)
HIGH ALERT MEDICATIONS (HAMS)
• … those that are most likely to cause
significant harm to the patient, even when used
as intended.
• … those medications with the highest
percentage of, or potential for, medication
errors and/or sentinel events and that carry a
high risk for abuse, errors or other adverse
outcomes.
Institute for Healthcare Improvements (IHI)
The Joint Commission (JCAHO)
EXTRA CAUTIONARY LABELS
 Guideline on safe use of high alert medications
WHEN IT HAPPEN?
 Which one is less important?
X
Who?
Why?
Medication Safety
Medication Safety
Medication Safety
WHEN A MEDICATION ERROR OCCURS, ORGANIZATION WIDE
SYSTEM WEAKNESSES ARE OFTEN IDENTIFIED IN :
 How information is collected and communicated,
 How colleagues interact,
 How patients and staff are educated,
 How the organizational culture and physical
environment are managed,
 How staff is provided to carry out patient care
functions,
 How staff learns about system errors and their causes,
and
 How patients are safeguarded from harm.
 Patient information
 Drug information
 Communication related to medications
 Drug labelling, packaging & nomenclature
 Drug standardization, storage & distribution
 Medication delivery device acquisition, use, and monitoring
 Environmental factors
 Staff competency & education
 Patient education
 Quality processes & risk management
INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) HAS
LISTED DOWN TEN KEY ELEMENTS THAT HAVE THE GREATEST
INFLUENCE ON MEDICATION USE:
CONCLUSION
 Medication error is common and is causing preventable
human suffering and financial cost
 Remember that using medications to help patients is not a
risk-free activity
 Interdisciplinary interactions go a long way toward preventing
errors
 Know your responsibilities and work hard to make medication
use safe for your patients
GUIDELINES AVAILABLE IN MOH
THANK YOU
Pusat Maklumat Ubat @ Drug Information Centre, IKN
Ext: 3434 or 3435
Unit Farmasi Klinikal
Ext: 7114 or 7115
MEDICATION LABEL

Weitere ähnliche Inhalte

Was ist angesagt?

look alike and sound a like medications
   look alike and sound a like medications   look alike and sound a like medications
look alike and sound a like medicationsMEEQAT HOSPITAL
 
Medication Safety- Administration and monitoring.pptx
Medication Safety- Administration and monitoring.pptxMedication Safety- Administration and monitoring.pptx
Medication Safety- Administration and monitoring.pptxLatha Venkatesan
 
Medication errors powerpoint
Medication errors powerpointMedication errors powerpoint
Medication errors powerpointlexie_daryan
 
LASA Drugs FINAL PPT (1).pptx medcell
LASA Drugs FINAL PPT (1).pptx medcellLASA Drugs FINAL PPT (1).pptx medcell
LASA Drugs FINAL PPT (1).pptx medcellVir Sharma
 
Look alike and sound alike medications
Look alike and sound alike medicationsLook alike and sound alike medications
Look alike and sound alike medicationsMEEQAT HOSPITAL
 
High alert & lasa medications
High alert & lasa medicationsHigh alert & lasa medications
High alert & lasa medicationsHatch Compliance
 
Medication Safety Presentation
Medication Safety PresentationMedication Safety Presentation
Medication Safety PresentationDien Vu
 
medication error reporting system
 medication error reporting system medication error reporting system
medication error reporting systemMEEQAT HOSPITAL
 
Medication errors: Causes, Assessment, Evaluation and Prevention
Medication errors: Causes, Assessment, Evaluation and PreventionMedication errors: Causes, Assessment, Evaluation and Prevention
Medication errors: Causes, Assessment, Evaluation and PreventionDr. Abhimanyu Prashar
 
MANAGEMENT OF MEDICATION IN HOSPITALS
MANAGEMENT OF MEDICATION IN HOSPITALSMANAGEMENT OF MEDICATION IN HOSPITALS
MANAGEMENT OF MEDICATION IN HOSPITALSDr.Jeena Salim
 
Medication errors
Medication errorsMedication errors
Medication errorsserag35
 
Medication error- Etiology and strategic methods to reduce the incidence of M...
Medication error- Etiology and strategic methods to reduce the incidence of M...Medication error- Etiology and strategic methods to reduce the incidence of M...
Medication error- Etiology and strategic methods to reduce the incidence of M...Dr. Jibin Mathew
 
Safety in medication administration
Safety in medication administrationSafety in medication administration
Safety in medication administrationkiran
 

Was ist angesagt? (20)

look alike and sound a like medications
   look alike and sound a like medications   look alike and sound a like medications
look alike and sound a like medications
 
Medication safety
Medication safetyMedication safety
Medication safety
 
High Alert Medication
 High Alert Medication  High Alert Medication
High Alert Medication
 
Medication errors
Medication errorsMedication errors
Medication errors
 
Medication Safety- Administration and monitoring.pptx
Medication Safety- Administration and monitoring.pptxMedication Safety- Administration and monitoring.pptx
Medication Safety- Administration and monitoring.pptx
 
Medication error
Medication errorMedication error
Medication error
 
Medication error
Medication errorMedication error
Medication error
 
Medication errors powerpoint
Medication errors powerpointMedication errors powerpoint
Medication errors powerpoint
 
LASA Drugs FINAL PPT (1).pptx medcell
LASA Drugs FINAL PPT (1).pptx medcellLASA Drugs FINAL PPT (1).pptx medcell
LASA Drugs FINAL PPT (1).pptx medcell
 
Look alike and sound alike medications
Look alike and sound alike medicationsLook alike and sound alike medications
Look alike and sound alike medications
 
Medication error
Medication errorMedication error
Medication error
 
High alert & lasa medications
High alert & lasa medicationsHigh alert & lasa medications
High alert & lasa medications
 
Medication Safety Presentation
Medication Safety PresentationMedication Safety Presentation
Medication Safety Presentation
 
medication error reporting system
 medication error reporting system medication error reporting system
medication error reporting system
 
High alert medication
High alert medicationHigh alert medication
High alert medication
 
Medication errors: Causes, Assessment, Evaluation and Prevention
Medication errors: Causes, Assessment, Evaluation and PreventionMedication errors: Causes, Assessment, Evaluation and Prevention
Medication errors: Causes, Assessment, Evaluation and Prevention
 
MANAGEMENT OF MEDICATION IN HOSPITALS
MANAGEMENT OF MEDICATION IN HOSPITALSMANAGEMENT OF MEDICATION IN HOSPITALS
MANAGEMENT OF MEDICATION IN HOSPITALS
 
Medication errors
Medication errorsMedication errors
Medication errors
 
Medication error- Etiology and strategic methods to reduce the incidence of M...
Medication error- Etiology and strategic methods to reduce the incidence of M...Medication error- Etiology and strategic methods to reduce the incidence of M...
Medication error- Etiology and strategic methods to reduce the incidence of M...
 
Safety in medication administration
Safety in medication administrationSafety in medication administration
Safety in medication administration
 

Andere mochten auch

Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)Shaukat Patel MS R.Ph.
 
Gap analysis of NABH 3rd and 4th Edition
Gap analysis of NABH 3rd and 4th EditionGap analysis of NABH 3rd and 4th Edition
Gap analysis of NABH 3rd and 4th EditionDr.Deepak Rajendiran
 
Medication Safety
Medication SafetyMedication Safety
Medication Safetyrmullenger
 
Role of the pharmacist in medication safety.
Role of the pharmacist in medication safety.Role of the pharmacist in medication safety.
Role of the pharmacist in medication safety.Subash321
 

Andere mochten auch (6)

Medication Errors
Medication ErrorsMedication Errors
Medication Errors
 
Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)
 
Gap analysis of NABH 3rd and 4th Edition
Gap analysis of NABH 3rd and 4th EditionGap analysis of NABH 3rd and 4th Edition
Gap analysis of NABH 3rd and 4th Edition
 
Medication Safety
Medication SafetyMedication Safety
Medication Safety
 
Medical errors
Medical errorsMedical errors
Medical errors
 
Role of the pharmacist in medication safety.
Role of the pharmacist in medication safety.Role of the pharmacist in medication safety.
Role of the pharmacist in medication safety.
 

Ähnlich wie Medication Safety

IT Assistant for Elderly People to avoid medication errors
IT Assistant for Elderly People to avoid medication errorsIT Assistant for Elderly People to avoid medication errors
IT Assistant for Elderly People to avoid medication errorskaveesha7
 
The Medication Error Reporting Project
The Medication Error Reporting ProjectThe Medication Error Reporting Project
The Medication Error Reporting ProjectKristina Camacho
 
American Holocaust
American HolocaustAmerican Holocaust
American HolocaustRay Gebauer
 
HOW TO MINIMIZE MEDICATION ERROR
HOW TO MINIMIZE MEDICATION ERRORHOW TO MINIMIZE MEDICATION ERROR
HOW TO MINIMIZE MEDICATION ERRORJawed Quazi
 
STUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTEDSTUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTEDSeema Wilson
 
STUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTEDSTUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTEDSeema Wilson
 
Medication Errors, types, reporting, prevention
Medication Errors, types, reporting, preventionMedication Errors, types, reporting, prevention
Medication Errors, types, reporting, preventionDr. Ankit Gaur
 
ICU to stop all sustaining.docx
ICU to stop all sustaining.docxICU to stop all sustaining.docx
ICU to stop all sustaining.docx4934bk
 
Final dissertation
Final dissertationFinal dissertation
Final dissertationAjeetRai13
 
6Medical Mistakes and Patient SafetyFlirtSuperStock.docx
6Medical Mistakes and  Patient SafetyFlirtSuperStock.docx6Medical Mistakes and  Patient SafetyFlirtSuperStock.docx
6Medical Mistakes and Patient SafetyFlirtSuperStock.docxtroutmanboris
 
MALPRACTICE IN MEDICAL DIAGNOSIS.pptx
MALPRACTICE IN MEDICAL DIAGNOSIS.pptxMALPRACTICE IN MEDICAL DIAGNOSIS.pptx
MALPRACTICE IN MEDICAL DIAGNOSIS.pptxalwakilm
 
PICOTIn hospitalized medsurg patients , does med reconciliatio.docx
PICOTIn hospitalized medsurg patients , does med reconciliatio.docxPICOTIn hospitalized medsurg patients , does med reconciliatio.docx
PICOTIn hospitalized medsurg patients , does med reconciliatio.docxstilliegeorgiana
 
Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)Shaukat Patel MS R.Ph.
 

Ähnlich wie Medication Safety (20)

Prabhjot Saini.pptx
Prabhjot Saini.pptxPrabhjot Saini.pptx
Prabhjot Saini.pptx
 
IT Assistant for Elderly People to avoid medication errors
IT Assistant for Elderly People to avoid medication errorsIT Assistant for Elderly People to avoid medication errors
IT Assistant for Elderly People to avoid medication errors
 
Pharmacoepidemiology
Pharmacoepidemiology Pharmacoepidemiology
Pharmacoepidemiology
 
The Medication Error Reporting Project
The Medication Error Reporting ProjectThe Medication Error Reporting Project
The Medication Error Reporting Project
 
American Holocaust
American HolocaustAmerican Holocaust
American Holocaust
 
HOW TO MINIMIZE MEDICATION ERROR
HOW TO MINIMIZE MEDICATION ERRORHOW TO MINIMIZE MEDICATION ERROR
HOW TO MINIMIZE MEDICATION ERROR
 
STUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTEDSTUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTED
 
STUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTEDSTUDY ABSTRACT CORRECTED
STUDY ABSTRACT CORRECTED
 
Medication Errors, types, reporting, prevention
Medication Errors, types, reporting, preventionMedication Errors, types, reporting, prevention
Medication Errors, types, reporting, prevention
 
ICU to stop all sustaining.docx
ICU to stop all sustaining.docxICU to stop all sustaining.docx
ICU to stop all sustaining.docx
 
Final dissertation
Final dissertationFinal dissertation
Final dissertation
 
6Medical Mistakes and Patient SafetyFlirtSuperStock.docx
6Medical Mistakes and  Patient SafetyFlirtSuperStock.docx6Medical Mistakes and  Patient SafetyFlirtSuperStock.docx
6Medical Mistakes and Patient SafetyFlirtSuperStock.docx
 
American Journal of Emergency & Critical Care Medicine
American Journal of Emergency & Critical Care MedicineAmerican Journal of Emergency & Critical Care Medicine
American Journal of Emergency & Critical Care Medicine
 
Polypharmacy and medication errors
Polypharmacy and medication errorsPolypharmacy and medication errors
Polypharmacy and medication errors
 
Emergency med pharmacist 2017 coralic a. et al
Emergency med pharmacist 2017 coralic a. et alEmergency med pharmacist 2017 coralic a. et al
Emergency med pharmacist 2017 coralic a. et al
 
MALPRACTICE IN MEDICAL DIAGNOSIS.pptx
MALPRACTICE IN MEDICAL DIAGNOSIS.pptxMALPRACTICE IN MEDICAL DIAGNOSIS.pptx
MALPRACTICE IN MEDICAL DIAGNOSIS.pptx
 
Rational prescribing & prescription writing
Rational prescribing & prescription writingRational prescribing & prescription writing
Rational prescribing & prescription writing
 
rational prescribing & prescription writing
rational prescribing & prescription writingrational prescribing & prescription writing
rational prescribing & prescription writing
 
PICOTIn hospitalized medsurg patients , does med reconciliatio.docx
PICOTIn hospitalized medsurg patients , does med reconciliatio.docxPICOTIn hospitalized medsurg patients , does med reconciliatio.docx
PICOTIn hospitalized medsurg patients , does med reconciliatio.docx
 
Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)Med safety nj ph a 10 10 11 final 3 (97-2003)
Med safety nj ph a 10 10 11 final 3 (97-2003)
 

Mehr von Pharmacy @ Institut Kanser Negara

CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...
CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...
CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...Pharmacy @ Institut Kanser Negara
 
Oncology Drugs: The journey From Manufacturer To The End User
Oncology Drugs: The journey From Manufacturer To The End UserOncology Drugs: The journey From Manufacturer To The End User
Oncology Drugs: The journey From Manufacturer To The End UserPharmacy @ Institut Kanser Negara
 

Mehr von Pharmacy @ Institut Kanser Negara (11)

CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...
CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...
CLINICAL AUDIT: ADHERENCE TO ANTIBIOTIC PROPHYLAXIS FOR CHEMOPORT INSERTION G...
 
Computerized physician order entry (cpoe) and
Computerized physician order entry (cpoe) andComputerized physician order entry (cpoe) and
Computerized physician order entry (cpoe) and
 
The affordable way forward for cancer treatment in malaysia
The affordable way forward for cancer treatment in malaysiaThe affordable way forward for cancer treatment in malaysia
The affordable way forward for cancer treatment in malaysia
 
Drug Purchasing & Pricing : industry perspective
Drug Purchasing & Pricing : industry perspectiveDrug Purchasing & Pricing : industry perspective
Drug Purchasing & Pricing : industry perspective
 
The value of generics and biosimilar drugs
The value of generics and biosimilar drugsThe value of generics and biosimilar drugs
The value of generics and biosimilar drugs
 
Oncology Drugs: The journey From Manufacturer To The End User
Oncology Drugs: The journey From Manufacturer To The End UserOncology Drugs: The journey From Manufacturer To The End User
Oncology Drugs: The journey From Manufacturer To The End User
 
An Introduction to Health Economics
An Introduction to Health EconomicsAn Introduction to Health Economics
An Introduction to Health Economics
 
Health Technology Assessment : Interpreting a HTA report
Health Technology Assessment : Interpreting a HTA reportHealth Technology Assessment : Interpreting a HTA report
Health Technology Assessment : Interpreting a HTA report
 
Setting the threshold for reimbursement of a treatment
Setting the threshold for reimbursement of a treatmentSetting the threshold for reimbursement of a treatment
Setting the threshold for reimbursement of a treatment
 
Oncology Treatment Guidelines : The Rules and Rationale
Oncology  Treatment Guidelines :The Rules and RationaleOncology  Treatment Guidelines :The Rules and Rationale
Oncology Treatment Guidelines : The Rules and Rationale
 
Cancer 2014: Why do we need a focus on value?
Cancer 2014: Why do we need a focus on value?Cancer 2014: Why do we need a focus on value?
Cancer 2014: Why do we need a focus on value?
 

Kürzlich hochgeladen

Practical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxPractical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxKatherine Villaluna
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...CaraSkikne1
 
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxPISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxEduSkills OECD
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxheathfieldcps1
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...Nguyen Thanh Tu Collection
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17Celine George
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxAditiChauhan701637
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationMJDuyan
 
Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.EnglishCEIPdeSigeiro
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17Celine George
 
Prescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptxPrescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptxraviapr7
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRATanmoy Mishra
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesMohammad Hassany
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxDr. Santhosh Kumar. N
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17Celine George
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17Celine George
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptxSandy Millin
 
Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptxClinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptxraviapr7
 
Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.raviapr7
 

Kürzlich hochgeladen (20)

Practical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxPractical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptx
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...
 
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxPISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptx
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
 
Finals of Kant get Marx 2.0 : a general politics quiz
Finals of Kant get Marx 2.0 : a general politics quizFinals of Kant get Marx 2.0 : a general politics quiz
Finals of Kant get Marx 2.0 : a general politics quiz
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptx
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive Education
 
Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17
 
Prescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptxPrescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptx
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming Classes
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptx
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
 
Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptxClinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptx
 
Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.
 

Medication Safety

  • 1. Jabatan Farmasi Institut Kanser Negara MEDICATION SAFETY
  • 2.  Richard Smith, who had a history of kidney disease, had been admitted to the ICU after a dialysis session where he experienced severe shortness of breath. The next day, July 30, 2010, he complained of an upset stomach, so the doctor prescribed the antacid.  The day his daughter came by to visit that morning, and found his dad "unconscious, unresponsive and on a respirator.“  "The nurse said my dad had coded. I said, 'He coded? When did that happen?‘”  The doctor told him, "I'm sorry to have to tell you this but the nurse administered the wrong medication and sent your dad into respiratory arrest.“  "He said the packaging looked the same and he grabbed the wrong package,“  The nurse is wrongly given pancuronium instead of antacid. UPSET STOMACH TO CODE RED
  • 4. MEDICATION ERROR - DEFINITION “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. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, US)
  • 5. TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM
  • 6. Healthcare is nearly 10 years behind other industries in its efforts to reduce errors. Michael A. Jackson, BS Pharm, RPh Wesley G. Reines, PharmD
  • 7. “MEDICATION ERROR : SIMPLE MISTAKE CAN BE LETHAL” Medication Safety Is Everyone’s Responsibilities “PLEASE DO NO HARM”
  • 8. MEDICATION ERROR: WHY THE CONCERN?  The impact of medication safety incidents on patient outcomes includes increased length of stay, disability and mortality ( V i n c e n t e t a l . , 2 0 0 1 , U K )  Medication errors are estimated to account for at least 7,000 deaths in the United States alone every year. Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999, p. 1 .  Over 770,000 patients are estimated to be injured because of medication errors every year. A g e n c y f o r H e a l t h R e s e a r c h a n d Q u a l i t y , 2 0 0 1  At least 1 death occurs per day and 1.3 million people are injured each year due to medication errors. Food and Drug Administ rat ion (FDA), US  Medication error is one of the most common causes of unintentional harm in Australia which results in an estimated 80,000 hospital admissions every year ( S e n a t o r K a y P a t t e r s o n , F e d e r a l M i n i s t e r f o r H e a l t h a n d A g e i n g A u s t r a l i a , 9 S e p t e m b e r 2 0 0 3 )
  • 9. MEDICATION ERROR: WHY THE CONCERN?  Medication errors occur in nearly 1 out of every 5 doses given to patients in the typical hospital. ( R e f e r e n c e : B a r k e r K N , F l y n n E A , P e p p e r G A , P h D , B a t e s D W , M i k e a l R L . M e d i c a t i o n e r r o r s o b s e r v e d i n 3 6 h e a l t h c a r e f a c i l i t i e s . A r c h I n t e r n M e d 2 0 0 2 ; 1 6 2 : 1 8 9 7 - 1 9 0 3 . )  One 5-year study showed that the most common types of medication errors were a wrong dose, a wrong drug or a wrong route of administration. ( R e f e r e n c e : P h i l l i p s J , B e a m S , B r i n k e r A , H o l q u i s t C , H o n i g P , L e e L Y , P a m e r C . R e t r o s p e c t i v e a n a l y s i s o f m o r t a l i t i e s a s s o c i a t e d w i t h m e d i c a t i o n e r r o r s . A m J H e a l t h S y s t P h a r m . O c t 2 0 0 1 . 5 8 ( 1 9 ) ; 1 8 3 5 - 4 1 )  Adverse medication events have been reported and are estimated to occur at a rate of around 5% for admissions and discharges from the typical hospital. ( R e f e r e n c e : C l a s s e n D C , P e s t o n i k S L , E v a n s R S , L l o y d J F , B u r k e J P . A d v e r s e d r u g e v e n t s i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 7 ; 2 7 7 : 3 0 1 - 3 0 6 . L a z a r o u J , P o m e r a n z B H , C o r e y P N . I n c i d e n c e o f a d v e r s e d r u g r e a c t i o n i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 8 ; 2 7 9 : 1 2 0 0 - 1 2 0 5 . )  Several studies point to more than 50% of potential and serious adverse events being associated with injectable medications. (R e f e r e n c e : K a u s h a l R , B a t e s D W , L a n d r i g a n C , e t a l . M e d i c a t i o n e r r o r s a n d a d v e r s e d r u g e v e n t s i n p e d i a t r i c i n p a t i e n t s . J A M A 2 0 0 1 ; 2 8 5 : 2 1 1 4 - 2 1 2 0 . T h o m a s E J , B r e n n a n T A . I n c i d e n c e a n d t y p e s o f p r e v e n t a b l e a d v e r s e e v e n t s i n e l d e r l y p a t i e n t s : p o p u l a t i o n b a s e d r e v i e w o f m e d i c a l r e c o r d s . B M F 2 0 0 0 ; 3 2 0 : 7 4 1 - 7 4 4 . )
  • 10. MEDICATION ERROR: WHY THE CONCERN?  The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year. This estimate does not take into account lost wages and productivity or additional healthcare costs " P r e v e n t i n g M e d i c a t i o n E r r o r s : Q u a l i t y C h a s m S e r i e s ” , I O M R e p o r t , J u l y 2 0 0 6  IOM issued a report on the prevalence of medication errors in the United States in which at least 1.5 million Americans are injured every year by medication errors.
  • 11. Martin A Makary, and Michael Daniel BMJ. 2016;353:bmj.i2139
  • 13. WHERE CAN MEDICATION ERROR OCCUR? Medication error may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”
  • 15. Prescribing Transcribing Dispensing Administering Medication Management Processes Errors • Wrong Dose • Wrong Drug • Wrong Route/Form • Allergy • Drug Interaction • Wrong Dose • Wrong Drug • Wrong Route • Wrong Time • Wrong Patient • Wrong Dose • Wrong Drug • Wrong Route • Wrong Time • Wrong Patient • Incorrect Labelling • Primary Catch for allergy, drug interaction • Wrong Dose • Wrong Drug • Wrong Route • Wrong Time/ Omitted • Wrong Patient • Incorrect Labelling
  • 16. MEDICATION SAFETY IS EVERYONE’S RESPONSIBILITIES The Pharmaceutical Services Division has always placed emphasis on medication safety and its strategies are in line with those of the Patient Safety Council of Malaysia Strategies to Improve Medication Safety Reporting & Learning Dissemination of Information Guidelines Education & Empowerment
  • 18. MEDICATION ERROR REPORTS  Current medication error are reported to:  United States Pharmacopeia  ISMP  Medwatch reports  Manufacturer reports  UK : National Reporting and Learning System (NRLS), National Patient Safety Agency (NPSA)  Australia : NSW Health Incident Information Management System(IIMS), Queensland Health Clinical Incident Information System (PRIME CI) in Queensland  Malaysia : MERS
  • 19. MEDICATION ERROR REPORTING SYSTEM (MERS)
  • 20. MEDICATION ERROR (ME) REPORTING SYSTEM (MERS) Purpose: a) To obtain information on the occurrence of medication errors b) To maintain a database on medication errors c) To analyse the report d) To propose remedial actions and monitor the situations e) To minimize the reoccurrence of such errors
  • 21. NUMBER OF ME REPORTS RECEIVED BY YEAR 2572 4120 5003 6011 8422 16897 43025 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 0 5000 10000 15000 20000 25000 30000 35000 40000 45000 50000
  • 22. PROCESS IN WHICH THE ERROR OCCUR 2387 3568 3290 4017 5229 13056 139 421 1131 1433 2645 3301 44 84 407 416 398 326 2 5 41 37 31 32 0 42 134 108 119 182 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 Combination Others Administration Dispensing Prescribing
  • 24. CONTRIBUTING FACTORS OF ME 12003, 48% 8759, 35% 3066, 12% 1106, 5% 2014 Staff Factors Work Environment Task & Technology Medication Related
  • 25. Contributing Factors No of Reports Total Medication Related Look alike medication 317 1106 Look alike packaging 337 Sound alike medication 452 Staff Factors Distraction 3455 12003 Inadequate knowledge 2369 Inexperienced personnel 6179 Task & Technology Failure to adhere to work procedure 1647 3066 Illegible prescription 646 Incorrect computer entry 101 Patient information/record/ unavailable/ inaccurate 507 Use of abbreviations 165 Work & Environment Heavy workload 2566 8759 Peak hour 5492 Stock arrangements/ storage problem 260 Wrong labeling/ instruction on dispensing envelope or bottle/ container 441
  • 27. ERROR-PRONE ABBREVIATION Abbreviation Intended meaning Common Error U Units Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. µg Micrograms Mistaken for "mg" (milligrams) resulting in an overdose. Q.D. Latin abbreviation for every day The period after the "Q" has sometimes been mistaken for an " I, " and the drug has been given "QID" (four times daily) rather than daily. Q.O.D. Latin abbreviation for every other day Misinterpreted as "QD" (daily) or "QID" (four times daily). If the "O" is poorly written, it looks like a period or "I."
  • 28. ERROR-PRONE ABBREVIATION Abbreviation Intended meaning Common Error SC or SQ Subcutaneous Mistaken as "SL" (sublingual) when poorly written. D/C Discharge; also discontinue Patient's medications have been prematurely discontinued when D/C, (intended to mean "discharge") was misinterpreted as "discontinue," because it was followed by a list of drugs. IU International Unit Mistaken as IV (intravenous) or 10(ten)
  • 29.  MMF – MTF  HCT – HCTZ – HCQ  CBZ – CPZ  IVIg vs Human Albumin ERROR-PRONE ABBREVIATION
  • 30. HOW TO PREVENT ERROR?  Use generic names for drug. Avoid trade names.  Avoid using abbreviations  Write clear instructions Daonil Glibenclamide X √ MTF Metformin X √ Gutt. CMC BD Gutt. CMC 2 drops RE BD X √
  • 31. HOW TO PREVENT ERROR?  Use leading zero before decimal point  Avoid trailing zero after decimal point Avoid verbal orders Identify patient drug allergies .5 mg 0.5 mg X √ 5.0 mg 5 mg X √
  • 33. LOOK ALIKE SOUND ALIKE MEDICATIONS (LASA) Medications that are:  Visually similar in physical appearance or packaging  Name of the medications that have spelling similarities
  • 34. Inj. Vitamin K 1mg/ml Inj. Neostigmine Inj. Vitamin K 10mg/ml
  • 35. SOUND ALIKE MEDICATIONS  Clotrimazole – Co-trimoxazole  Oxycontin - Oxynorm  Dopamine - Dobutamine  Adrenaline - Atropine  Noradrenaline – Adrenaline
  • 36. HOW TO PREVENT ERROR?  Double checking the drug (dispensing/administering)  (Pharmacist) Contacting the prescribers in case of any clarification regarding the prescription (DO NOT ASSUME)  Becoming familiar with LASA medications  Separating LASA medications from one another  Using Tall Man Lettering  Installing warning system to staff – Computer alerts or warnings on stock bottles
  • 37. SEPARATING LASA MEDICATIONS FROM ONE ANOTHER
  • 39. TALL MAN LETTERING No Medication No Medication No Medication No Medication 1 ATRAcurium 13 DOBUTamine 25 LOsartan 37 PANTOprazole 2 BISOprolol 14 DOXOrubicin 26 LOVAstatin 38 PERINDOpril 3 BUPIvacaine 15 DOPamine 27 metFORMIN 39 progyLUTON 4 carBAMAZepine 16 DuphASTON 28 METOprolol 40 ProgyNOVA 5 carBIMazole 17 DuspaTALIN 29 NEostigmine 41 ProSCAR 6 cefOTAXime 18 ENALApril 30 NeuroBION 42 PROzac 7 cefTAZIDime 19 ESOMEprazole 31 NeuroNTIN 43 ROcuronium 8 cefTRIAXone 20 FORTzaar 32 niFEDipine 44 ROPIvacaine 9 chlorproMAZINE 21 gliBENclamide 33 niMODipine 45 SETRAline 10 chlorproPAMIDE 22 gliCLAzide 34 nitroGLYCERINe 46 STELLAzine 11 COzaar 23 LANSOprazole 35 nitroPRUSSIDe 47 VEcuronium 12 DAUNOrubicin 24 LIGNOcaine 36 PANcuronium 48 vinBLAStine
  • 42. FENTANYL PATCH - HOW TO CUT Needs to be cut DIAGONALLY 6 MCG/HR 6 MCG/HR Only for 6mcg/hr dose For 12mcg/hr dose, use 25mcg/hr patch (cut into half) 12 MCG/HR 12 MCG/HR
  • 43. FENTANYL PATCH - HOW TO ADMINISTER 12 MCG/HR DOSE HOW TO ADMINISTER 6 MCG/HR FOR 3 DAYS ½ patch 12mcg/hr 18 MCG/HR FOR 3 DAYS ½ patch 25mcg/hr + ½ patch 12mcg/hr 6mcg/hr 6mcg/hr12mcg/hr +
  • 44.  Guide On Handling Look Alike Sound Alike Medications
  • 45. HIGH ALERT MEDICATIONS (HAMS)  Drugs that bear a heightened risk of causing significant patient harm when they are used in error.  Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. Institute for Safe Medication Practice (ISMP)
  • 46. HIGH ALERT MEDICATIONS (HAMS) • … those that are most likely to cause significant harm to the patient, even when used as intended. • … those medications with the highest percentage of, or potential for, medication errors and/or sentinel events and that carry a high risk for abuse, errors or other adverse outcomes. Institute for Healthcare Improvements (IHI) The Joint Commission (JCAHO)
  • 48.  Guideline on safe use of high alert medications
  • 49. WHEN IT HAPPEN?  Which one is less important? X Who? Why?
  • 53. WHEN A MEDICATION ERROR OCCURS, ORGANIZATION WIDE SYSTEM WEAKNESSES ARE OFTEN IDENTIFIED IN :  How information is collected and communicated,  How colleagues interact,  How patients and staff are educated,  How the organizational culture and physical environment are managed,  How staff is provided to carry out patient care functions,  How staff learns about system errors and their causes, and  How patients are safeguarded from harm.
  • 54.  Patient information  Drug information  Communication related to medications  Drug labelling, packaging & nomenclature  Drug standardization, storage & distribution  Medication delivery device acquisition, use, and monitoring  Environmental factors  Staff competency & education  Patient education  Quality processes & risk management INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) HAS LISTED DOWN TEN KEY ELEMENTS THAT HAVE THE GREATEST INFLUENCE ON MEDICATION USE:
  • 55. CONCLUSION  Medication error is common and is causing preventable human suffering and financial cost  Remember that using medications to help patients is not a risk-free activity  Interdisciplinary interactions go a long way toward preventing errors  Know your responsibilities and work hard to make medication use safe for your patients
  • 57. THANK YOU Pusat Maklumat Ubat @ Drug Information Centre, IKN Ext: 3434 or 3435 Unit Farmasi Klinikal Ext: 7114 or 7115

Hinweis der Redaktion

  1. Greetings! Assalamulaikum Salam sejantera Thank you for attending today talk, today I would like to talk about an important issues in patient care. Medication safety in an big issues but somehow smaller subset of medical errors. During this talk you will heard me using Medication Error, Medical Errors interchangeably.
  2. Lets start our session with two case report. Case No 1 – Mr Smith, who is known case of kidney disease and on regular dialysis. Admitted to ICU after a dialysis session because of SOB. The next day, he complaint stomach upset hence his doctor prescribed antacid. The next day, his daughter came by to visit and found that his dad was unconscious and on a respirator. The nurse in-charged inform that, his dad had a code red. Upon asking the doctor who taking care of his dad – she found that the nurse administered the wrong medication. He said the packaging looked the same and he grabbed the wrong package. The nurse is wrongly given pancuronium which is muscle relaxant instead of antacid.
  3. According to National Coordinating Council for Medication Error Reporting and Prevention, US; Medication error can be defined as any preventable event that 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.
  4. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
  5. Healthcare is nearly 10 years behind other industries in its efforts to reduce errors.
  6. According to a publish paper in British Medical Journal 2016 by Makary and Daniel. Medical error is a third leading caused of death after heart disease and cancer which account for 251k death in US.
  7. In Malaysia, we already seen a few case reported in local newspaper. This case become viral on social media. This however, just a gist of unreported medical error/negligence.
  8. Prescribing- Doctor Transcribing – Nurse, previously Dispensing – Pharmacist Administering – Nurse-IP; Patient-OP Monitoring – Doctor.
  9. What type of errors can occur during this process.
  10. Medication safety is everyone’s responsibilities. Not only for pharmacist – its for all healthcare professional. There is for strategies to improve medication safety as placed by MOH Patient Safety Council of Malaysia. Reporting and learning from mistake. Dissemination of information – disseminate what the latest issues in patient safety. Guidelines – provide guidelines to reduced medication errors. Education and empowerment – educated all healthcare personal regarding medication errors and empower them to report and discuss about medication safety.
  11. There is ways to prevent errors such as: Prescribing – electronic prescription – reduced risk of transcribing errors. Admixture and labeling – prepared by skill pharmacist technician and label to minimize error. Scanning – bar code scanning to minimized error. Check data and start – check patient information before serving medication. Documentation – document all process involved.
  12. This form can be fill by anybody including patient. Not necessary must be fill by pharmacist.
  13. In 2009, there is 2572 case of ME being reported to MERS. This report has double in 2010 and subsequently increased to 16897 cases in 2014. Which shown 8x increment from 2009.
  14. The most common process in which the error occur are during prescribing – manual prescribing. Follow by dispensing and administration.
  15. What are the contributing factors of ME? Staff factors New/In-experience. Lack of training Lack of empowerment Careless Not focus Work and environment Small area Noisy environment. Medication related Look a like sound a like Same medication, different strength. Task and technology Not femilar with technology.
  16. In 2014- based on report form MERS. The main contributing factor of ME are staff factor followed by work environment, task and technology and medication related. Hmmm, medication related which account for 5% are not a big issues compared to others. So we are blaming the medication where our big problem are staff factors.
  17. Staff factor are the main source of ME: Inexperienced personnel/Inadequate knowledge – are we train our staff enough? Did we under-train them? Distraction – did we give them conducive environment to work? Other main important contributing factor of ME are, sound alike medication. Failure to adhere to work procedure – for example need counter checking – did we properly counterchecking each and everyone? Heavy workload – understaff?. Peak hour when a lot of patient need to be entertained.
  18. So we encourage to write full name rather than sing abbreviation.
  19. Stick to 5B/5R rules. Always ask patient name before giving medication Give the right medication Give the right dose Using right route at a right time – warfarin give at 6pm. CCRT to give drugs before patient undergoes RT. Give patient insulin 30mins before meals.
  20. Double checking the drug – that why we have check by column in the FISICIEN. Contact prescriber for any ambiguity List down the LASA medication – educate staff.
  21. When it happen. It not who are important but why its happen are more important. We are not jugging or blaming who involved but we are more interested on why its happen and how to overcome its.
  22. So when its happen, what you will do? REPORT! Do not hide errors caused latter on it will known eventually.
  23. Some fact about what happen to WHO involved in ME.
  24. So how to reduced harm??? Improve reporting and learning – discussed and learn regarding medication errors. Improve transfer of medicines and information between care setting – share information regarding patient safety, disseminate new info regarding new product especially change of product and dosage. Improve implementation of patient safety alerts – drug interaction alrets.
  25. Check label for correct dose and instruction.