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Matthew Grissinger, RPH, FISMP, FASCPManager, Medication Safety AnalysisPennsylvania Patient Safety AuthorityABSTRACTPennsylvania facilities submitted 879 medication error reports from July 1, 2004, through January 31, 2011, to the Pennsylvania Patient Safety Authority involving patients taking their own medications while in a hospital. According to the Institute of Medicine report, titled “To Err Is Human: Building a Safer Health System”, it was first reported in 1999 that between 44,000 and 98,000 Americans die in hospitals each year due to mistakes in their care. Whenever you are prescribed a medication, you must be sure that you understand the key sections of the medication’s label in order to ensure your safety. Rx Outreach is a non-profit pharmacy whose mission is to provide affordable medications to people in need. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising.
Have you ever given your child a liquid medication?  If so, there is a pretty good chance that you may have given your child the wrong dose.  This topic was the subject of a recently published article in the American Academy of Pediatrics.  The study found that approximately 40% of parents made an error in giving liquid medicine! As a pharmacist, I have always lamented the use of kitchen spoons to give medicine; and as the Director of the IPC, I see firsthand how confusing it can be for parents to correctly dose their child’s medicine.  Here are some examples of dosing confusion—it can happen to anyone! I can’t thank you enough for this because it can be totally confusing to give the proper dosage when all you’re trying to do is help your child get better!
As humans we are always susceptible to make errors, but understanding why we make them will help us design systems that decrease the chances of such errors to happen. Eg: The nurse is distracted in her busy shift and gives a medication to her patient which was intended for another patient. The rule based errors or cognitive errors are very interesting and if you wish to learn more then refer to this brief article by Dr. Latent Errors :   Latent errors are accidents waiting to happen because of defects in the design of the system.
The label on your prescription bottle contains information from your doctor and your pharmacy about using your medication correctly. The warning labels are usually on the side or back and are often separated from the main label. Use a dosing cup or syringe and always ask your pharmacist—or call the IPC helpline at 1-800-222-1222—if you have a question on how to measure medication.
I am now forearmed with the correct information needed to better care for my loved ones and was moved to post this blog on my Facebook page for others to benefit from as well! If this is your first time here, you must check out A Day in the Life of a Poison Center and You might say the Illinois Poison Center is the Antidote to Unnecessary Health Care Costs. Almost 300 different medications were mentioned in the reports, and 18.7% of the reports revealed that patients took multiple medications.
It was then said that more people die from medical errors each year than from breast cancer or from motor vehicle accidents. That is why it is now believed that errors are not made by defective people, but by defective systems.
One or more controlled substances were involved in 40.3% of the events, and more than 25% of the reports mentioned a medication considered to be a high-alert medication. As if these figures were not staggering enough, a study was published recently in the Journal of Patient Safety that estimated the annual number of medical errors in U.S. Because one day the attending doesn’t have time to go over every detail about patient care and this unsupervised intern prescribes the wrong medication leading to active error. If it says “three times a day”, take the medication at three intervals, such as morning – afternoon – evening.
Employing strategies to prevent harm from patients taking their own medications can be prioritized by proactively assessing the risk associated with patients bringing in their own medications, developing a screening process for patients admitted to the facility who have a previous history of bringing in their own medications, and providing patient and family education upon admission to the facility about the facility’s policies in regard to patients’ use of their own medications.IntroductionThe medications prescribed for and administered to patients while they are hospitalized are typically provided by the hospital’s pharmacy department.
However, there are times when it may be necessary for a patient to bring his or her own medications into the hospital. With this medical errors stands as the third leading cause of death after myocardial infarction and cancer.
For example, patients are often asked to bring their medications with them so that an accurate medication list can be generated for medication reconciliation. If the drug the patient needs is not on the hospital’s formulary and the hospital has no alternative therapy, the patients’ personal medications may be used to avoid an interruption in therapy.1 Some patients also may bring their medications from home to the hospital in hopes of saving money. Many patients desire to self-medicate with their own medicines while in the hospital to ease anxiety over the loss of self-control of their care.2 Hospitals of all sizes face challenges in managing patients’ personal medications. Larger institutions and government hospitals generally maintain larger inventories of medications and have closed formularies. Smaller community and rural hospitals may not have the space or funds to maintain a large inventory of medications and, therefore, may be more likely to allow patients to use their own medications.
A survey of directors of pharmacy at small hospitals (300 beds or less) found that a majority (90.9%) of the hospitals allowed patients to use their own medications while in the hospital.
Before use or administration of a medication brought into the hospital by a patient, his or her family, or a licensed independent practitioner, the hospital identifies the medication and visually evaluates the medication’s integrity.
The hospital informs the prescriber and patient if the medication brought into the hospital by patients, their families, or licensed independent practitioners is not permitted. Pennsylvania facilities have submitted a number of reports to the Pennsylvania Patient Safety Authority mentioning errors with the use of patients’ own medications, many indicating staff have found medications in a patient’s room that were brought from home without the hospital staff’s knowledge. There is scarce literature that addresses situations in which patients bring in their own medications, and a comprehensive search found no literature that discussed patients taking their own medications unbeknownst to the healthcare staff.


Analysis of events reported to the Authority in which patients used their own medications has determined the most common types of events, patient populations involved, medications involved, and reasons why patients bring their medications to the hospital, as reported in Pennsylvania.Aggregate Analysis of Patients Bringing Their Own Medications into the Hospital While reviewing reports submitted to the Authority, analysts have the opportunity to further classify reports, using a “monitor code,” for future querying opportunities. Analysts queried the Authority’s database for reports assigned the monitor code “PE1,” representing reports identified as errors involving patients using their own medications.
In addition, the event descriptions were queried for phrases such as “own meds” to identify reports that may involve patients taking their own mediations that were not assigned the “PE1” monitor code. The query yielded 879 medication error reports that had been submitted to the Authority from July 1, 2004, through January 31, 2011.
Predominant Medication Error Event Types Associated with  Patients Taking Their Own Medications (n=746, 84.9% of total reports),  July 1, 2004, to January 31, 2011Events took place in 68 different care areas, as selected by facilities.
This does not include reports where no medications were mentioned (n = 114, 13%).Patient found unresponsive. In 2010, two million people reported using prescription painkillers for nonmedical purposes for the first time within the last year—this equates to nearly 5,500 people per day.6 The unprecedented rise in overdose deaths in the United States parallels a 300% increase since 1999 in the sale of opioid painkillers. Patient took the Soma and Valium by crushing the medications and self-administering via her gastrointestinal tube.
The medications were discovered in the patient’s personal belongings along with a syringe and pill crusher. In addition, empty bottles for [containing] Zanaflex®, Vicodin, and Darvocet® were found in the patient’s drawer.
The patient’s parent brought in the patient’s home supply, and the nurse said the child could take that because the fever needed to be treated.
The nurse went out to get an oral syringe, and when he came back to the room, the mother said she gave the child what “seemed like a lot of Tylenol.” The nurse asked how much, and the parent said 20 mL, which would be 640 mg. The doctor was notified and labs were obtained, which showed an acetaminophen level of 30 and liver functions tests [serum glutamic oxaloacetic transaminase and serum glutamate pyruvate transaminase] increased significantly. More than 25% (n = 220) of the reports mentioned a medication that would be considered to be a high-alert medication in either the acute or ambulatory care settings.9,10 Of the 25 most commonly mentioned medications (see Table 2), 10 (40%) were high-alert medications. Most of these high-alert medications were opioids, but two medications, insulin and warfarin, were not. Forty percent (n = 28) of the 70 events involving high-alert medications resulted in patients being transferred to a higher level of care.  Table 2.
Top 25 Medications Involved in Medication Errors  in Events in which Patients Took Their Own Medications  (n = 526, 59.8% of total reports) Reasons Patients Bring Their Own MedicationsAnalysts also reviewed event descriptions to determine if reporting facilities mentioned the reasons why patients felt the need to bring in and self-administer their own medications. Most of the reports submitted to the Authority involved situations in which the patients brought in their medications without informing facility staff and self-administered them. However, at least 45 reports (5.1%) described errors that occurred in which organizations were intentionally using patients’ own medications. A nurse gave an extra dose of fenofibrate [which was the patient’s own medication] instead of the thalidomide that was scheduled. The patient’s thalidomide [also her home medication] was later found in another patient’s drawer.
The next dose of fenofibrate was held and thalidomide was administered.Vytorin® [a combination tablet of ezetimibe 10 mg and simvastatin 20 mg] was ordered for the patient.
The pharmacy substituted Zetia® [ezetimibe] 10 mg and Zocor® [simvastatin] 20 mg to use for Vytorin, and that was printed on medication administration record. Patients were unaware that the directions for a particular medication were different in the hospital compared with at home. Patients were simply unaware that they should not take their own medications while in the hospital.The patient used the call bell and asked to speak to the med nurse.
The medications administered included Zanaflex® 8 mg, Coumadin 5 mg, and docusate sodium 100 mg.
She stated that her husband brought them in and that she took “everything, Dilantin®, phenobarbital, Colace®, all of them.” The doctor was notified and order was given to hold the medications. The lab alerted the staff that the patient had open bottles of medication on her bed with some of them spilled on the floor. When the patient was asked what she was doing, she stated she didn’t get enough medicine so she was taking her own. When asked what she took, she stated that she took baby aspirin, heart pills, and Synthroid®.
Over 12.6% (n = 111) of the reports indicated that patients self-administered their own medications because they were not completely satisfied with the care they were receiving. For example, patients stated that their pain was poorly controlled, that they were “tired of waiting” for their medication, or that their disease was not being adequately treated while in the hospital.The nurse discovered that the patient had medicated himself with insulin, indicating that he was concerned that staff did not medicate him in a timely manner. The patient had Humalog® insulin along with insulin syringes in his room, apparently from home.
The medication and syringes were removed from the patient’s room.A five-year-old patient was seizing for about six to seven minutes, with the doctor in the room.
The mother took the medication Diastat® [diazepam] out of a bag and gave [the patient] the medication, saying there was no time for a third party to retrieve [the medication]. The patient’s father was upset with the delay of medications reaching the nursing unit for his daughter. This medication was not approved by pharmacy.A patient was agitated about their elevated glucose readings for the past two checks.


Adjustments were made to NovoLog® scale during the day shift; however, following the last elevated glucose reading, the patient expressed concerns about inadequate treatment. Calls were made to the resident to explain the situation; patient was assured that a sliding scale order would be entered for the elevated reading, but no order was received. Risk Reduction Strategies Many institutions are confronted with managing the patient’s own medications that are brought in from home, and organizations can have procedures in place for the control and administration of these medications.
Consider the strategies described in this section, which are based on a review of events submitted to the Authority and observations at the Institute for Safe Medication Practices:Proactively assess the risk associated with the use of patients’ own medications.
If patients are asked to bring in medications only for reconciliation purposes, explain to the family why the medications were needed and encourage them to take the medications home. If the facility does not need to use a patient’s medications, explain to the patient and family the policy on bringing in prescription, over-the-counter, and herbal or homeopathic medications into the facility.Review medication administration records (MARs) to determine how the directions for patients’ own medications are expressed. Examples of circumstances allowing for personal medication use could include the following: The medication is not available on the hospital’s formulary, including those medications that are part of a restricted distribution system, compounded by an outside specialty pharmacy, investigational medications, and controlled substances.
The patient is on a continuous parenteral infusion of such medications as Flolan®, Remodulin®, or an insulin pump.1Develop an alternative plan to provide the medication to the patient if the pharmacy is unable to supply it before the next dose is due. For example, stating that if a patient’s home medication must be used, it should be administered by a nurse.
Address the pharmacy’s role in this process, including the following: If the medications are not to be allowed for use, return them to the patient’s family or caregivers.
Ensure a process is in place to return the medications to the patient or family on discharge from the facility. Specify that the pharmacist is the health professional who will identify the medications, and include guidelines for another health professional to identify these medications if the pharmacist is unavailable.
In one published account of a hospital’s assessment of medications that patients brought to the hospital, pharmacists were able to identify 95% of the medications, with 1 in 15 containers of these medications being mislabeled or unlabeled.11 Develop a process to ensure the proper labeling of any patient’s personal medications that are allowed for use in accordance with state regulations, making sure that the medications are identifiable, in good condition, and not expired.
Specific challenges to be addressed include the following:Changes in the frequency of administration. For example, if a patient was taking their medication from home once daily but the directions have changed in the hospital to two times a day.The use of bar codes. If the organization uses bar coding at the point of care, the pharmacy will need to apply a bar code to each medication brought in by the patient for use within the facility.Before medications are sent to the nursing unit, place stickers or some other means of notification on containers for the medications that have been reviewed by a pharmacist. Use a documented tracking mechanism to communicate the use of patients’ personal medications, especially when patients bring in controlled substances or investigational medications. Develop a standardized approach in regard to the storage of patients’ own medications in the patient care area. In accordance with hospital policy, report any adverse events associated with the use of patients’ personal medications. Ensure procedures are in place to return patients’ personal medications before discharge, and note the final disposition of the medications in the pharmacy records.ConclusionIn Pennsylvania, almost 900 medication errors have been reported from July 1, 2004, through January 31, 2011, involving patients taking their own medications while in healthcare facilities, many times unbeknownst to healthcare practitioners. One or more controlled substances were involved in over 40% of these events reported to the Authority, and more than 25% of these reports mentioned high-alert medications.
Employing proactive strategies to address situations in which patients may bring in their own medications and implementing a screening method for patients admitted to the facility with a previous history of bringing in their own medications can be steps that are prioritized to prevent potential harm to patients.NotesNorstrom PE, Brown CM. Results from the 2010 national survey on drug use and health: summary of national findings [online].
Drug Abuse Warning Network: selected tables of national estimates of drug-related emergency department visits.
Patients do not realize that the directions for a particular medication are different in the hospital compared with at home. Patients are not told that they should not take their own medications while in the hospital. Which of the following statements reflect standards from the Joint Commission?The hospital defines when medications brought into the hospital by patients or their families cannot be administered. After the use or administration of a medication brought into the hospital by a patient, the hospital identifies the medication and visually evaluates the medication’s integrity.The hospital informs the prescriber and patient if the medication brought into the hospital by patients is permitted. The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners.
Insulin and warfarin were the types of high-alert medications mentioned most often in the reports.While in the hospital, a patient self-administered atenolol 50 mg from her own supply. The patient brought in her medication from home because she thought that it was okay to take her high blood pressure medicine. However, the patient’s attending physician had not ordered this medication for the patient. What proactive strategies may help to prevent these types of errors?Develop a screening method for patients admitted to the facility who have a previous history of bringing in their own medications.
Inform the patient and family upon admission to the facility about the facility’s policies in regard to patients’ use of their own medications. If the medication was brought in for reconciliation purposes, ask the patient’s family to take the medication home.



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