Causes of medication errors pdf reader,7 s of project management,type ii diabetes medications list - PDF 2016

I ntegration of predictive and retrospective risk analysis in health care Tjerk van der Schaaf Leiden University Medical Center Eindhoven University of. CHERNOBYL Human Reliability Definition: “The probability that a person will correctly perform some system-required activity during a given time period. A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient. On March 11, 2008, FDA informed health care professionals about adverse events and deaths in children and adults who have taken Tussionex Pennkinetic Extended-Release Suspension (Tussionex).
Hydrocodone, the narcotic ingredient in this medicine that controls cough, can cause life-threatening breathing problems when too much medicine is given at one time or when the medicine is given more frequently than recommended. Roughly 7,000 children ages 11 and younger are treated in hospital emergency rooms each year because of overdoses of OTC cough and cold medication, according to a recent study by the Centers for Disease Control and Prevention. OTC cough and cold products can be harmful if more than the recommended amount is used, if they are given too often, or if more than one product containing the same active ingredient is used. Serious injuries and deaths have resulted from such errors as misunderstanding directions and failing to use the measuring devices that come with the medicine.
To avoid accidental overdosing, consumers should not take more than the recommended dose on the label. FDA has issued warnings about the fentanyl transdermal system, an adhesive patch that delivers an opioid called fentanyl through the skin. The directions on the product label and package insert of the fentanyl transdermal system should be followed exactly in order to avoid overdose. FDA has issued a public health advisory cautioning practitioners to avoid overdoses when they are prescribing methadone or managing patients taking the drug.
Since the 1970s, methadone has been primarily used in treating drug abuse, but it is increasingly being used to treat pain.
Both edetate disodium and edetate calcium disodium work by binding with heavy metals or minerals in the body, allowing them to be passed out of the body through the urine.
In January 2008, FDA issued a public health advisory, warning that some children and adults have died when they were mistakenly given edetate disodium instead of edetate calcium disodium (calcium disodium versenate), or when edetate disodium was used for chelation therapies and other uses not approved by FDA. To minimize drug name confusion, FDA reviews about 400 drug names a year that companies submit as proposed brand names. FDA works with drug companies to reduce the risk of errors that may result from similar-looking labeling and packaging, or from poor product design. In accordance with an FDA rule that went into effect in 2004, bar codes are required on product labels for certain drugs and biologics such as blood. FDA reviews about 1,400 reports of medication errors per month and analyzes them to determine the cause and type of error.
FDA is working on three new guidances—one on complete submission requirements for anaylsis of trade names, one about the pitfalls of drug labeling, and another on best test practices for naming drugs. FDA spreads the message about medication error prevention through public health advisories, medication guides, and outreach partnerships with other organizations.
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Errors involving medication administration can be costly, both financially and in human terms. When asked to identify the most common factors that contribute to injectable medication errors, 78 percent of nurses surveyed cite their rushed workload and busy environment. Prescribing Safely Kevin Gibbs Pharmacy Manager: Clinical Services University Hospitals Bristol NHS Foundation Trust.
GP records - 2 Private prescriptions may not be recorded on GP computer Private prescriptions may not be recorded on GP computer Watch the date last issued Watch the date last issued Has this been stopped?
Other common pitfalls Prescribed & labelled As directed Prescribed & labelled As directed Own tablets not brought in Own tablets not brought in Several possible strengths eg inhalers Several possible strengths eg inhalers Trade names – beware duplicates Trade names – beware duplicates Patient cant remember Patient cant remember Dosett boxes X tablet identification Dosett boxes X tablet identification Asking about your tablets – Patients will then miss off inhalers, creams etc!
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Introducing the exclusive tokidoki back-to-school collection, featuring innovative bags, stationery, and coloring products. The potential for drug misadventures, adverse drug reactions, and medi cation errors is a reality. Since 2000, the Food and Drug Administration (FDA) has received more than 95,000 reports of medication errors. For example, miscommunication of drug orders can involve poor handwriting, confusion between drugs with similar names, poor packaging design, and confusion of metric or other dosing units.
Overdose of Tussionex in older children, adolescents, and adults has also been associated with life-threatening and fatal breathing problems. About two-thirds of those incidents occurred when children took medication without a parent's knowledge. In January 2008, FDA issued a public health advisory recommending that OTC cough and cold products not be used in infants and children under 2.
For more information, see OTC Cough and Cold Products: Not for Infants and Children Under 2 Years of Age.
The drug is sold under brand names such as Tylenol and Datril, and is also available in many cough and cold products, prescription pain relievers, and sleep aids. Also, acetaminophen should not be taken for more days than recommended, and should not be taken with other drug products that also contain acetaminophen without direction from a health care provider. For example, the infant drop formula is three times more concentrated than the children's liquid. Fentanyl patches should not be used for short-term acute pain, pain that is not constant, or for pain after an operation. Recent reports to FDA describe deaths and life-threatening side effects after doctors and other health care professionals inappropriately prescribed the patch to relieve pain after surgery, for headaches, or for occasional or mild pain in patients who were not opioid tolerant.
The patients replaced the patch more frequently than directed in the instructions, applied more patches than prescribed, or applied heat to the patch. FDA issued the advisory because of reports of life-threatening adverse events and death in patients receiving methadone for pain control.
When used with bar code scanner and computerized patient information systems, bar code technology can help ensure that the right dose of the right drug is given to the right patient at the right time.


The establishment of a hospital patient safety program that includes medication labeling protocols can help to reduce such errors, which can range from a patient receiving an incorrect dosage of a medication to receiving incorrect medication. Discuss the pitfalls of drug history taking Discuss the pitfalls of drug history taking Introduce medicines reconciliation Introduce medicines reconciliation Help you to reduce risk from prescribing medicines Help you to reduce risk from prescribing medicines Identify sources of information which will help you prescribe safely Identify sources of information which will help you prescribe safely Revision from 3 rd year talk!
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. Verification: Collection of the medication history Obtaining a complete and accurate list of each patient's current medications (medication history) including name, dosage, frequency and route Obtaining a complete and accurate list of each patient's current medications (medication history) including name, dosage, frequency and route 2. Systematic review showed 30-70% for unintentional variances between the medication patients are taking and their subsequent in-patient prescriptions 1 Systematic review showed 30-70% for unintentional variances between the medication patients are taking and their subsequent in-patient prescriptions 1 Examples Examples Omeprazole started in ITU for prevention of stress ulceration. Enabling JavaScript in your browser will allow you to experience all the features of our site.
Every error is potentially tragic and cost ly in both human and economic terms, for patient and professional alik e. The patch is only for moderate-to-severe chronic pain that is expected to last for any number of weeks or longer and that cannot be managed by acetaminophen-opioid combinations, nonsteroidal analgesics, or as-needed dosing with short-acting opioids.
Like other opioids, methadone causes slowed breathing, affects heart rate, and can also interact with other drugs.
Edetate disodium was approved as an emergency treatment for certain patients with very high levels of calcium in the blood or certain patients with heart rhythm problems resulting from high amounts of the medication digoxin in the blood.
For more information, review The Joint Commission's 2006 Critical Access Hospital and Hospital National Patient Safety Goals, which includes suggestions for how to avoid medication administration errors. Is the patient no longer taking the medicine Is the patient no longer taking the medicine Adverse reaction?
Easy to pick up a relatives medicines by mistake Easy to pick up a relatives medicines by mistake Easy to miss if the same surname Easy to miss if the same surname Are they still taking these? Clarification : Ensuring that the medications and doses are appropriate Comparing the in-patient prescription or TTA to the medication history Comparing the in-patient prescription or TTA to the medication history 3.
Medication Errors is the most comprehensive, authoritative examinat ion of the causes of and means to preventing medication errors ever wr itten. An overdose can occur because methadone stays in the body longer than the pain relief lasts.
Stopped without GP being aware Stopped without GP being aware Stopped with GP agreement but still on GP list Stopped with GP agreement but still on GP list Stopped a while ago but kept just in case Stopped a while ago but kept just in case Contents of medicine cupboard emptied! Cohen, president of the Institute for Safe Medicatio n Practices, and nearly two dozen other experts on the subject dissect the problem in 20 chapters.
A systematic review of the effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission.



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