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  • Medication Errors 19 Sep15

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    drbharatmalhotr195
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    This document discusses medication errors in hospitals. It notes that medication errors are one of the most common and preventable types of errors. The failure is often due to problems in practice, procedures, products or systems rather than individual failure. Checklists, protocols, reminders and feedback can help reduce complexity, optimize information processing and mitigate errors. The document provides examples of how hospitals can improve systems to achieve safe patient practices, such as defining medicine cabinets, educating patients, and implementing prophylaxis protocols and checklists particularly in intensive care. The key is taking responsibility to change systems and reduce harm from medical errors.

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    This document discusses medication errors in hospitals. It notes that medication errors are one of the most common and preventable types of errors. The failure is often due to problems in practice, procedures, products or systems rather than individual failure. Checklists, protocols, reminders and feedback can help reduce complexity, optimize information processing and mitigate errors. The document provides examples of how hospitals can improve systems to achieve safe patient practices, such as defining medicine cabinets, educating patients, and implementing prophylaxis protocols and checklists particularly in intensive care. The key is taking responsibility to change systems and reduce harm from medical errors.

    Copyright:

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    Markieren Sie unangemessene Inhalte
    10 Ansichten36 Seiten

    Medication Errors 19 Sep15

    Hochgeladen von

    drbharatmalhotr195
    This document discusses medication errors in hospitals. It notes that medication errors are one of the most common and preventable types of errors. The failure is often due to problems in practice, procedures, products or systems rather than individual failure. Checklists, protocols, reminders and feedback can help reduce complexity, optimize information processing and mitigate errors. The document provides examples of how hospitals can improve systems to achieve safe patient practices, such as defining medicine cabinets, educating patients, and implementing prophylaxis protocols and checklists particularly in intensive care. The key is taking responsibility to change systems and reduce harm from medical errors.

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    von 36

    Medication Errors

    By Dr Bharat Malhotra
    Classified Med Spl Mil Hospital

    Errors and Patient safety


    Lesson learnt from near tragedy

    SCIENCE OF
    MEDICINE

    Vs

    Sentinel Events

    Key to reducing harm is


    taking on responsibility to
    change

    Deaths due to Medical Errors in USA

    Institute of Medicine :
    To err is human 1999 & Medical Errors 5 years after IOM report

    Why focus on medication-related


    error?
    One of the most common types of error

    Substantial numbers of individuals are


    affected
    Accounts for a sizable increase in
    health care costs
    One of the most preventable error

    Medication - Errors

    Unreported

    What is Medication Error?


    The failure of a planned
    action to be completed as
    intended
    or the use of a wrong plan
    to achieve an aim.
    Errors
    can
    include
    PRACTICE
    PROCEDURES
    problems in:
    PRODUCTS

    SYSTEMS

    Adverse Events VS Medication Errors

    Example

    Tenectiplase : Use as thrombolytic in Acute M


    Adverse Event : 1.8% incidence of stroke

    Which Patients are most at


    risk?

    gency Room

    xperienced Doctor

    ICU

    Complex
    Old patients Medical

    Types of Medical Errors

    PROPHYLAXIS ERRORS

    DIAGNOSIS ERRORS

    PRESCRIBING ERRORS

    PRESCRIBING ERRORS

    DOCUMENTING ERRORS

    DISPENSING ERRORS

    ADMINISTRATION ERRORS

    OTHER ERRORS

    Addressing problem - Adverse Event

    NO ACTION REQUIRED

    Addressing problem - Medical Error

    ACTION REQUIRED

    How to think of error?


    System failure and not individual failure

    Management

    Workload

    Unsafe acts

    Equipment

    Omissions

    Knowledge
    Ability

    Reeva lederman ; Systems Failure in hospitals. Using Reasons Model :


    Journal of Medical Systems, Vol. 29, No. 1, February 2005

    How to Respond?
    Reduce complexity
    Optimize information processing
    Checklist
    Protocols
    Reminders

    Feedback on recurrent error patterns


    Mitigate unwanted side effects of drugs TRAINING

    Let us see how we can improve systems at a Zonal Hospital


    setting

    ACHIEVE SAFE PATIENT


    PRACTICES

    MI Room / Casualty
    Medical Kit/
    Bag

    Equipment
    Check

    MI Room / Casualty
    Redefine
    Medicine Cabinet

    Inexperienced N/Asst
    (understand
    limitations)

    OPD Complex / Med Store Dispensing


    NO SHOT GUN APPROACH
    Prescribe Scientifically
    Clear handwriting
    Explain dose/frequency
    Define next review

    OPD Complex / Med Store Dispensing


    Diabetic Educator
    (insulin Advise)

    COPD / ASTHMA
    Educator

    OPD Complex / Med Store Dispensing


    Complex Disease
    (Multiple Medicines)

    High Risk
    Medicine

    Look alike Sound Alike Medicine (LASA)

    ICU / Critical Care


    PROPHYLAXIS
    ANTIBIOTIC
    POLICY
    INFUSION DOSE
    MONITOR /
    MODIFY DOSE
    CENTRAL LINE/
    CATHETERS CARE

    DRUG
    INTERACTIONS

    Protocols & Checklists

    HIGHLY RATED PATIENT SAFETY PRACTICE in ICU

    Prophylaxis for DVT at risk


    Periop: Beta blocker
    Sterile barrier Central venous lines
    Antibiotic Policy
    Continuous aspiration Subglotic region Avoid VAP
    Pressure sores: beds/ skin care
    Appropriate nutrition Emphasis : early Enteral
    Institute of Medicine :
    To err is human 1999 & Medical Errors 5 years after IOM report

    NABH ACCREDITATION OF
    HOSPITAL

    10 Chapters

    514 objective elements

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