Medications errors
نبأ حسيب: الصيدالنية
Objective : ● What is the medication errors?
● What is the types of
medication errors ?
● Scale of errors and
contributory factors.
● medication errors Prevention .
What is the
medication
errors? Adverse drug events, adverse drug reactions and
medication errors Adv drug reactions Adverse drug
events, adverse drug reactions and medication errors
Q/ What is :
● Adverse drug
events,
● adverse drug
reactions
● medication
errors
● Adverse drug
events,
defined as “any injury resulting from
medical interventions related to a
drug” including:
● preventable and predictable,
( medication errors,)
● not predictable.( adverse drug
reactions (ADRs)
medication errors
, defined as “any preventable event that may cause or lead
to inappropriate medication use or patient harm .
What is the
1. Prescribing error:mistake made by the
types of
prescriber include errors in indication,
medication drug–disease interactions, drug–drug
errors ? interactions, dosing errors and
inappropriate prescribing.
2. Transcribing : occur during order
An error occurring at any communication due to incorrect data
stage that reaches a recording by health and care workers
patient may result in 3. Dispensing errors: are defined as
harm and could involve deviation from the prescriber’s order,
everyone in the made by staff in the pharmacy
medication use process 4. Administration error : Any discrepancy
between how a medicine is given to a
patient and the directions for
administration
5. Monitoring error :Failure to review a
Medication
errors Some of these factors are:
contributory 1. Extremes of age
factors 2. Multimorbidity
3. Polypharmacy
Medication errors occur in all
health care settings 4. High-risk (high-alert) medicines
● .The recent systematic review 5. Antimicrobials and resistance
of 100 studies on preventable
medication harm indicated
6. Palliative care
that one in 20 patients is 7. Transitions of care
exposed to medication errors
Studies on medication errors have
8. Medicines as products
identified contributory factors 9. Health and care workers
related to patients, health and care
workers and medications 10.Health care systems
1.Extremes
Medication errors are most likely to occur in
of age
very young and older persons, who are less
likely to tolerate ADRs and have more
severe outcomes.
Older persons react differently from
younger people to medicines, because of
changes in organ function, the muscle:
body-fat ratio and the rate of clearance of
medicines.
2. Multimorbidity: ● Multimorbidity is defined as
the presence of two or more
long-term health conditions
● usually defined as concurrent
3. Polypharmacy: use of five or more medicines
that include over-the-counter,
prescription and/or T&CM
products
4.High-risk Many medicines pose a higher risk of harm
medicines when used in error anti-infective agents,
potassium and other electrolytes, opioids and
other sedatives, chemotherapeutic agents,
heparin and anticoagulants
Inappropriate and increasing use of
5. Antimicrobials antimicrobials has led to the development of
and resistance resistance,which increasingly difficult or even
impossible to treat
Infections
6. Palliative Most medical errors in palliative care are
care related to medicines used for symptom
control, particularly opioid analgesics
.7 Transitions Transitions of care are the physical
of care locations or contacts with a health care
professional to which a patient moves
or returns to receive health care
8. Health and Use of medicines involves collaboration
care workers among several health and care workers
.. Physical factors such as fatigue,
burnout, distraction and interruption,
poor information transfer and
psychological factors related to
inexperience,and workload reasons for
errors by health care staff
9. Health care The systems and environment in
systems high-income countries, with
electronic prescribing, bar-
coded dispensing, automated
devices for administration and
established error reporting and
learning systems, is more likely
to
prevent medication errors
10. Medicines 1. Substandard and falsified
medicin :
as products
2. “Look-alike and sound-alike”
medicine: The names, packaging or
labelling of medicines can be
confusing, and clear information is
sometimes lacking. Confusing “look-
alike and sound-alike” (LASA) names,
labelling and packaging are frequent
sources of error and medication-
related harm, with 6–14% of all errors
3. Medicines more likely to cause
harm
4. Traditional and complementary
: Incorrect, and inappropriate usage
of T&CM, even though of natural
origin can lead to unwanted effects.
Moreover, some medicinal plants are
inherently toxic.
● medicatio ● . 8 Ways to Reduce
n errors Medication Errors at Your
Pharmacy:
Preventio
n.
● The Five Rights of
Medication Administration
● Report medication errors
● 8 Ways to Reduce
Medication Errors at
Your Pharmacy:
Juggling multiple tasks such as
Avoid
1.1.
answering phone calls while handling
Multitasking drop-offs and also filling medication all
at once may be “efficient” but can
cause errors. delegate each member
of the team certain roles that they
would each be responsible for.
2. Reduce
Stress Finding ways to reduce stress
adding a technician to your team,
allowing college interns
, adding a coffee maker to the
pharmacy – anything that will bring
calmness
3. Organize There are several drugs that
lookalike and soundalike. It’s
Storage
important to ensure that they are
either stored away from each other
or that there is a distinct way to
differentiate them
4. Verify
Orders Mistakes can be made when
prescriptions are called in by phone
and not verified. It is important to
repeat the order back to ensure that
everything written down was heard
correctly.
5. Trust When you receive a script and
something doesn’t seem right, dig
Yourself deeper and call the prescriber or
question the patient. Sometimes
mistakes are made and other times
clarification is needed about why
6. Declutter something has been prescribed.
and Keep the
Try to put things back where they
Work Area belong,
Clean Keep every patient’s medication and
prescription separate to avoid mixing
them up.
Clear the counter and avoid leaving
open drinks and food near
prescriptions and medications.
7. Get to Know taking a minute or two to ask them
Your Patients questions can help catch any errors
before handing them a medication.
* Consider the Age of Your Patient
* Consider Liver and Kidney Function
* Consider Allergies
8) Implement
Technology to Improving your pharmacy workflow and
Streamline implementing technology that can help
Pharmacy Workflow reduce distractions and
interruptions ،so your team can focus
on making sure the patient care
● The Five
Rights of
1. The Right Person
Medication
Administratio 2. The Right Drug
n 3. The Right Dose
4. The Right Route
5. The Right Time
● Reporting medication errors
● The role of reporting is to
improve patient safety by
learning from failures
● Everyone in health care
system can report
medication error
