Medication Errors Workshop
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Medication Errors Workshop Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (HCQU). December, 2009 sc,alt. Disclaimer.

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December 2009 sc alt

Medication Errors WorkshopPresented by: APS HealthcareSouthwestern PA Health Care Quality Unit(HCQU)

December, 2009 sc,alt


Disclaimer

Disclaimer

Information or education provided by the HCQU is not intended to replace medical advice from the consumer’s personal care physician, existing facility policy or federal, state and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.

Certificates for training hours will only be awarded to those who attend a training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.


Note of clarification

Note of Clarification

While mental retardation (MR) is still recognized as a clinical diagnosis, in an effort to support the work of self-advocates, the APS SW PA HCQU will be using the terms intellectual and/or developmental disability (I/DD) to replace mental retardation (MR) when feasible.


Objectives

Objectives

Upon completion of the session the participant will:

  • 1. Describe how a systems approach can help to prevent/reduce medication errors

  • 2. Utilize key system elements to identify contributing factors to medication errors

  • 3. Analyze a medication error using the root cause analysis method


Workshop plan

Workshop Plan

  • Brief review of medication errors

  • Group activities

    • Identification of medication errors

    • Typing of medication errors

    • Categorizing of medication errors

  • Performance of root cause analysis


Medication error defined

Medication Error Defined

  • Preventable event

  • May cause/lead to inappropriate medication use or individual harm

  • Medication in control of healthcare professional or consumer

    National Coordinating Council for Medication Error Reporting and Prevention

  • Violation of one of five rights

  • Incorrect medication procedure

    Office of Developmental Programs


Where errors occur

Where Errors Occur


Types of medication errors

Types of Medication Errors

  • Omission

  • Commission


Errors of commission

Wrong dose

Wrong time

Wrong person

Wrong medication

Discontinued medication

Extra dose

Wrong medication

Wrong route

Wrong position

Wrong technique or method

Wrong form

Errors of Commission


Principles of medication error reduction prevention

Principles of Medication Error Reduction & Prevention

  • Goal of every organization

  • Use of systems approach

  • Assess risk

    • Failure mode and effects analysis (FMEA)

  • Assess errors and near misses

    • Root cause analysis (RCA)


Key system elements

Key System Elements

  • Policies & procedures

  • Individual information

  • Medication information

  • Communication

  • Medication names

  • Labeling & packaging

  • Standardization, storage, & distribution


Key system elements1

Key System Elements

  • Delivery systems

  • Environment & staffing

  • Competency & education

  • Individual education

  • Monitoring

  • Documentation

  • Quality improvement & risk management


Policies procedures

Policies & Procedures

  • Basis for medication use system

  • Govern sub-processes


Individual information

Individual Information

  • Vital to physician, pharmacist, and staff


Medication information

Medication Information

  • Current

  • Readily available

  • Identification of High Alert Medications


Communication

Verbal

B/W team members

Method used

Written

Prescriptions

Use of abbreviations, symbols, dose expressions

Communication


Medication names

Medication Names

  • Sound alike

  • Look alike


Labeling packaging

Labeling & Packaging

  • Similarities

  • Confusing

  • Mislabeling


Medication standardization storage distribution

Medication Standardization, Storage, & Distribution

  • Standards in place

  • Safe storage

  • Timely ordering and delivery


Medication delivery systems

Medication Delivery Systems

  • Syringes: Oral vs. Parenteral

  • Glucose monitors


Environment

Environment

  • Lighting

  • Noise

  • Temperature

  • Distractions

  • Interruptions

  • Unit organization


Staffing

Staffing

  • Physical health

  • Emotional health

  • Work schedule

  • Fatigue

  • Medications

  • Interpersonal relationships

  • Confirmation bias


Competency education

Competency & Education

  • Orientation

  • Certifications

  • Annual competencies

  • Skills labs

  • In-services


Program participant education

Program Participant Education

  • Knowledge of medications

  • Encouraged to ask questions


Monitoring

Monitoring

  • Adverse side effects/toxicity

  • Medication interactions

  • Diagnostic studies

  • Allergies


Documentation

Documentation

  • Standardized

  • Individual


Quality improvement risk management

Quality Improvement & Risk Management

  • Leadership

  • Non-punitive systems based approach

  • Error reporting


Benefits of systems based approach

Benefits of Systems Based Approach

  • Reduction of medication errors and near misses

  • Safer medication use system

  • Empowers staff

  • Morale improves


Group activities

Group Activities

  • Identification of medication errors

  • Typing of medication errors

  • Categorizing of medication errors

  • Performance of root cause analysis


References

References

Institute for Safe Medication Practices (2009). FAQ. Retrieved August 24, 2009 from , Web site: http://www.ismp.org/faq.asp

Cardinal Health (2009). Statistics. Retrieved August 24, 2009 from , Web site:http://www.legacycarefusion.com/clinicalcenter/education/statistics


References1

References

Morrow, J., & Breen, B. (2004). PA DPW OMR: Training how to administer medications the right way.

National Coordinating Council for Medication Error Reporting and Prevention ( 2009). What is a medication error?. Retrieved August 24, 2009 from , Web site:http://www.nccmerp.org/aboutMedErrors.html


References2

References

Folino, E. (2004). Medication errors: Preventing the preventable ppt.

National Coordinating Council for Medication Error Reporting and Prevention ( 2009). Council recommendations. RetrievedAugust 24, 2009 from , Web site:http://www.nccmerp.org/councilRecs.html


Suggested supplemental training

Suggested Supplemental Training

  • Medication Administration

  • Preventing & Reducing Medication Errors

  • Aging: Medication Management

  • Medication Side Effects


December 2009 sc alt

To register for future trainings,orfor more information on this or any other physical or behavioral health topic, please visit our website at www.hcqu.apshealthcare.com


December 2009 sc alt

EvaluationPlease take a few moments to complete the evaluation form found in the back of your packets.Thank You!


December 2009 sc alt

Test ReviewThere will be a test review after all tests have beencompleted and turned in to the Instructor.


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