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Medication Safety. A medication error is a drug error that may or may not reach the patient It is usually preventable It is usually unintentional May or May not cause harm A medication error that causes death is called a sentinel event by the Joint Commission

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Medication Safety

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    1. Medication Safety • A medication error is a drug error that may or may not reach the patient • It is usually preventable • It is usually unintentional • May or May not cause harm • A medication error that causes death is called a sentinel event by the Joint Commission • When a sentinel event occurs the institution is required to perform a root cause analysis

    2. Type of Medication Errors • Prescribing Errors • Involves wrong dose, illegible sigs, wrong frequencies • Incorrectly transcribing verbal orders from MD • Dispensing Errors • Results from mistakes made during dispensing • Physically preparing medications incorrectly (i.e. using 23.4% saline instead 0.9% saline for an IV admixture) • Transcribing sig instructions incorrectly • i.e. Methothexate 12.5 mg tablet TIW as 12.5 mg TID • Error in dosing calculations • Administration Errors • Involves nursing • Incorrect route of administration • Giving KCL 40 meq IVP instead of KCL 40 meq IVPB over 60 minutes (FATAL) • Giving Vincristine intrathecally instead of intravenously (Fatal) • Giving Penicillin G Benzathine IV instead of IM (can be fatal)

    3. Causes of Medication Errors • Performance problems • Procedure(s) not followed • Knowledge deficits • Pharmacists/Pharmacy Technicians that may be intoxicated by alcohol or drugs • Social or Family problems • Noise level at work • Distractions

    4. Medication Error Reduction Strategies • Joint Commission “Do not use” list • ISMP (Institute for Safe Medication Practices) error prone do not use list • See Lesson 3 “Medical and Pharmacy Terminology” • Also see • ISMP also publishes a list of confused drug names • Example concludes Celebrex-Celexa • List can be found at

    5. Tall Man Lettering • Tall Man lettering is a strategy implemented by healthcare institutions in the US under the advise of the Joint Commission , FDA and ISMP • Involves drug names that can be confused with one and other, see ISMP confused name’s list • Drugs with similar sounding names or spelling are called LASA drugs-Look Alike Sound Alike drugs • Tall man lettering involves the use of mixed case lettering to distinguish between these drugs • Examples: • buPROPion VS busPIRone • glyBURide VS glipiZIDE • hydrALAZINE VS hydrOXYzine • Tall man strategies involves: labeling of these medications, ADC cabinet display, separating these drugs on pharmacy shelves

    6. High Alert Medications • Medications that when used in error can result in serious patient harm including death • ISMP has collected a list of such drugs

    7. High Alert Medication Strategies • US hospitals and healthcare institutions have published their own lists that mirrors the ISMP list with some additions. • Strategies include: • Specialized color code labeling for these medications • Segregating the medications in the pharmacy inventory • Restricting access to these drugs in the ADC (non overrideable) • Specialized alerts in the CPOE and the pharmacy systems • Use of standardized preparations of these drugs • i.e. Heparin USP 25,000 units/250 ml D5W

    8. Do Not Crush List • ISMP publishes a do not crush list • These drugs should never be crushed • Typically patients that can’t swallow or have feeding tubes, NG tubes and PEG tubes have their oral dose forms crushed and administer in about 30 ml of liquid • Crushing some drugs alters their time course of activity, stability, or expose potential harm to pharmacy personnel • Drugs that are long acting • Effexor XR, Cardizem CD, Detrol LA, KDUR, Paxil CR, Seroquel XR • Drugs that are enteric coated • Ecotrin • Depakote • Nexium • Powerful GI irritant • Actonel® • Teratogenic (exposure to female pharmacy personnel) • Isotretinoin • Sublingual Dose Forms • Nitroglycerin •

    9. Medication Reconciliation • Medication Reconciliation (MedRecon) • Required by Joint Commission in accredited healthcare institutions • Designed to help prevent medication errors due to duplications, drug interactions and omissions • The process of medication review that is driven by the prescriber primarily • During Triage in the ER, a primary list of medications, OTC and herbals that patient is taking is to be generated (along with doses and indications) along with admission orders • During each transition of care (i.e. ER to inpatient unit, inpatient unit to critical care (ICU)) a review of this list is mandatory along with current inpatient medication list. Based on this, meds should be discontinued, maintained or changed with Transfer orders • Upon Discharge, the primary list is reviewed and a discharge medication list given to the patient explaining any changes to the patient. Discharge medication list is also to be provide to the patient’s primary care provider to update the patient’s care

    10. How to report med errors and adverse drug events • FDA Medwatch • ISMP MERP database • Institute of Medicine (IOM) • TJC (Joint commission) • USP Medmarx • FDA and CDC VAERS system for vaccines • FAERS is a database that contains information on med errors and adverse reaction

    11. Pharmacy Technician Role in Error Prevention • Question illegible handwritting on written prescriptions • Always keep Rx and labeling in mind when filling Rx • Carefully key in data in pharmacy system • Ask patient about OTC and herbal medications