med errors
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Patient Safety CME Curriculum
Patient Safety: The Other Side of theQuality Equation
Under a Grant fromUnder a Grant from
The Agency for Healthcare ResearchThe Agency for Healthcare Research
and Qualityand Quality
Principal InvestigatorPrincipal InvestigatorChristel MotturChristel Mottur--Pilson, PhDPilson, PhD
Director, Scientific PolicyDirector, Scientific Policy
ACPACP--ASIMASIM
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Patient Safety:
The Other Side of the Quality EquationSeven Modules in Ambulatory Care
SystemsSystems The influence of systems on the practice of medicine.The influence of systems on the practice of medicine.
Cognitive CapacityCognitive Capacity Coping mechanisms under information overload and timeCoping mechanisms under information overload and time
pressurespressures
CommunicationCommunication Communication barriers, lack, and unclearCommunication barriers, lack, and unclear
communicationcommunication
Medication ErrorsMedication Errors Uniform dosing, lookUniform dosing, look-- and soundand sound--alikes, forcing functionsalikes, forcing functions
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Patient Safety:
The Other Side of the Quality Equation
Seven Modules in Ambulatory Care
The Role of PatientsThe Role of Patients
Patients as allies in patient safetyPatients as allies in patient safety
The Role of ElectronicsThe Role of Electronics
Supportive products and processesSupportive products and processes
Idealized Office DesignIdealized Office DesignMedical practice design to supportMedical practice design to support
patient safetypatient safety
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Logistics
CME:CME: To receive your CME, please fill out the usualTo receive your CME, please fill out the usualformsforms
Evaluation formEvaluation formCME formCME form
Research Grant SurveysResearch Grant Surveys
PrePre--CME assessment of knowledge levelCME assessment of knowledge level
PostPost--CME assessment of knowledge levelCME assessment of knowledge level
SixSix--month follow up to CMEmonth follow up to CME
Virtual Patient Safety Electronic CommunityVirtual Patient Safety Electronic Community
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Preventing Medication
Errors Related ToPrescribing
Under a Grant fromUnder a Grant from
The Agency for Healthcare Research and QualityThe Agency for Healthcare Research and Quality
Developed by Michael R. Cohen, RPh, DScDeveloped by Michael R. Cohen, RPh, DSc
Institute for Safe Medication PracticesInstitute for Safe Medication Practices
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Medication Errors
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Medication Errors Reporting
Program
Operated by the
United States Pharmacopeia in cooperation
with the
Institute for Safe Medication Practices
Report medication errors in confidence:1 800 23 ERROR
www.ismp.org/www.usp.org
(USP and ISMP are FDA MEDWATCH partners)
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Where Do Errors Occur?
Prescribing 39%Transcribing 11%
Dispensing 12%
Administering 38%
Where Do Errors Occur?
Prescribing 39%Transcribing 11%
Dispensing 12%
Administering 38%
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Medication Prescribing Process
Components: Communication
Written Prescription OrdersWritten Prescription Orders
Medication Ordering SystemsMedication Ordering Systems
Electronic Order TransmissionElectronic Order Transmission
Dosage CalculationsDosage Calculations
Verbal OrdersVerbal Orders
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Written Medication Orders:
Illegible Handwriting 16% of physicians have illegible handwriting.16% of physicians have illegible handwriting.11
Common cause of prescribing errors.Common cause of prescribing errors.2, 3, 42, 3, 4
Delays medication administration.Delays medication administration.55
Interrupts workflow.Interrupts workflow. 55
Prevalent and expensive claim in malpracticePrevalent and expensive claim in malpractice
cases.cases.33
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Illegible Handwriting:
Error Prevention Prescribers ObligationPrescribers Obligation
Write/Print More CarefullyWrite/Print More Carefully
ComputersComputers
Verbal CommunicationsVerbal Communications
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Written Medication Orders:
Complete Information Patients NamePatients Name
PatientPatient--Specific DataSpecific Data
Generic and Brand NameGeneric and Brand Name Drug StrengthDrug Strength
Dosage FormDosage Form
AmountAmount
Directions for UseDirections for Use
PurposePurpose
RefillsRefills
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Written Medication Orders:
Patient-Specific Information AgeAge
WeightWeight
Renal and Hepatic FunctionRenal and Hepatic Function Concurrent Disease StatesConcurrent Disease States
Laboratory Test ResultsLaboratory Test Results
Concurrent MedicationsConcurrent Medications
AllergiesAllergies
Medical/Surgical/Family HistoryMedical/Surgical/Family History
Pregnancy/Lactation StatusPregnancy/Lactation Status
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Written Medication Orders:
Do Not Use Abbreviations Drug namesDrug names
QD or OD for the wordQD or OD for the word dailydaily
Letter U forLetter U forunitunit g forg formicrogrammicrogram (use mcg)(use mcg)
QOD forQOD forevery other dayevery other day
sc or sq forsc or sq forsubcutaneoussubcutaneous
a/ or & fora/ or & forandand
cc forcc forcubic centimetercubic centimeter
D/C forD/C fordiscontinuediscontinue orordischargedischarge
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Written Medication Orders:
Weights, Volumes, Units
Use metric systemUse metric system
Avoid apothecary systemAvoid apothecary system
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Case 3: Weights, Volumes,
Units
Confusion With Apothecary SystemConfusion With Apothecary System1/200 grain (0.3 mg)1/200 grain (0.3 mg) {{ 1/100 grain1/100 grain
(0.6 mg) + 1/100 grain (0.6 mg)(0.6 mg) + 1/100 grain (0.6 mg)
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Written Medication Orders: Decimals
Avoid whenever possibleAvoid whenever possible11
Use 500 mg for 0.5 gUse 500 mg for 0.5 g
Use 125 mcg for 0.125 mgUse 125 mcg for 0.125 mg
Never leave a decimal point nakedNever leave a decimal point naked 1, 2, 31, 2, 3
Haldol .5 mgHaldol .5 mg pp HaldolHaldol 0.5 mg0.5 mg
Never use a terminal zeroNever use a terminal zero
--Colchicine 1 mg not 1.0 mgColchicine 1 mg not 1.0 mg
Space between name and doseSpace between name and dose1,31,3
Inderal40 mgInderal40 mg pp Inderal 40 mgInderal 40 mg
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Written Medication Orders:
Drug Names
LookLook--Alike or SoundAlike or Sound--Alike DrugAlike DrugNamesNames
Confirmation BiasConfirmation Bias
Addition of SuffixesAddition of Suffixes
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Look-alike And Sound-alike
Drug Names
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Insert Figure 3Insert Figure 3
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Medication Prescribing Process:
Electronic PrescribingComputer with 3 Interacting DatabasesComputer with 3 Interacting Databases
Drug HistoryDrug History
Drug Information/Guidelines DatabaseDrug Information/Guidelines Database
PatientPatient--Specific InformationSpecific InformationAvoidsAvoids
Illegible PrescriptionsIllegible Prescriptions
Improper TerminologyImproper Terminology
Ambiguous OrdersAmbiguous Orders
Incomplete InformationIncomplete Information
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Computerized prescribing
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Dosage Calculations Recognized cause of medication errorsRecognized cause of medication errors
Use patientUse patient--specific informationspecific information
heightheight
weightweight
ageage
body system functionbody system function
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Dosage Calculations:
Error Prevention
Avoid calculationsAvoid calculations
CrossCross--checkingchecking
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Verbal Orders:
Error PreventionAvoid when possibleAvoid when possible
Enunciate slowly and distinctlyEnunciate slowly and distinctly
State numbers like pilotsState numbers like pilots
(i.e., one(i.e., one--five mg for 15 mg)five mg for 15 mg)
Spell out difficult drug namesSpell out difficult drug names
Specify concentrationsSpecify concentrations
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Conflict Resolution
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Patient Education
Educate patients about their medicationsEducate patients about their medications
Purpose of each medicationPurpose of each medication
Name of drug, dose, how to take, etc.Name of drug, dose, how to take, etc. Provide patients with understandable writtenProvide patients with understandable written
instructionsinstructions
Lack of involving patients in check systemsLack of involving patients in check systems
Inform patients about potential for error withInform patients about potential for error withdrugs known to be problematicdrugs known to be problematic
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Patient Education
Proper use of medication deliveryProper use of medication delivery
devicesdevices
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Preventing Medication
Prescribing Errors
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References
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Patient Safety Interactive
Learning Community (PSI
LC)
http://www.acponline.org/ptsafetyhttp://www.acponline.org/ptsafety
Program InformationProgram Information
& Updates& Updates
All Seven ModulesAll Seven Modules
Refresher ExercisesRefresher Exercises
Email DiscussionEmail Discussion
GroupsGroups
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Refresher Exercises
http://www acponline org/ptsafetyhttp://www acponline org/ptsafety
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