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Questions and Answers
What was the initially signed dosage of methotrexate according to the drug chart?
What was the initially signed dosage of methotrexate according to the drug chart?
What did the doctor rely on to verify the correct methotrexate dosage?
What did the doctor rely on to verify the correct methotrexate dosage?
What was the cause of death recorded on the patient's death certificate?
What was the cause of death recorded on the patient's death certificate?
During which stage do medication errors occur most frequently?
During which stage do medication errors occur most frequently?
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What percentage of medication errors is attributed to the administration stage?
What percentage of medication errors is attributed to the administration stage?
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What is the primary cause of most medication errors?
What is the primary cause of most medication errors?
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What is a key strategy for reducing medication errors?
What is a key strategy for reducing medication errors?
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How many sections are included in the Prescribing Safety Assessment (PSA)?
How many sections are included in the Prescribing Safety Assessment (PSA)?
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According to the content, what is essential for improving the rate of reporting medication errors?
According to the content, what is essential for improving the rate of reporting medication errors?
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What does the phrase 'To err is human, to cover up is unforgivable but to fail to learn is inexcusable' imply?
What does the phrase 'To err is human, to cover up is unforgivable but to fail to learn is inexcusable' imply?
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What are the key components of the medicines use process?
What are the key components of the medicines use process?
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What was the overall error rate for medication orders in the EQUIP study?
What was the overall error rate for medication orders in the EQUIP study?
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Which group of doctors had a slightly lower error rate for prescriptions according to the EQUIP study?
Which group of doctors had a slightly lower error rate for prescriptions according to the EQUIP study?
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Who is primarily responsible for administering medications in a hospital setting?
Who is primarily responsible for administering medications in a hospital setting?
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What was the outcome of the prescribing error in The Cambridgeshire Enquiry?
What was the outcome of the prescribing error in The Cambridgeshire Enquiry?
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What percentage of potentially lethal errors were found in prescriptions?
What percentage of potentially lethal errors were found in prescriptions?
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Which professionals are involved in the transcribing phase of the medication-use process?
Which professionals are involved in the transcribing phase of the medication-use process?
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What is one example of a prescribing error mentioned?
What is one example of a prescribing error mentioned?
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What role do pharmacists play in the context of prescribing errors?
What role do pharmacists play in the context of prescribing errors?
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What is a common thread among all team members involved in medication safety?
What is a common thread among all team members involved in medication safety?
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Which group is NOT primarily involved in the dispensing phase of the medication-use process?
Which group is NOT primarily involved in the dispensing phase of the medication-use process?
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Which of the following is NOT a recommended practice for risk management in prescribing?
Which of the following is NOT a recommended practice for risk management in prescribing?
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What error did the GP make during the prescribing process in The Cambridgeshire Enquiry?
What error did the GP make during the prescribing process in The Cambridgeshire Enquiry?
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What kind of errors can occur with electronic prescribing?
What kind of errors can occur with electronic prescribing?
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What is a common cause of prescribing errors related to handwriting?
What is a common cause of prescribing errors related to handwriting?
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What should healthcare professionals appreciate about using medicines safely?
What should healthcare professionals appreciate about using medicines safely?
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What should pharmacies avoid in order to reduce SALAD errors?
What should pharmacies avoid in order to reduce SALAD errors?
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Which of the following is NOT one of the myths of human error according to James Reason?
Which of the following is NOT one of the myths of human error according to James Reason?
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According to Reason's model, what contributes to error-producing conditions?
According to Reason's model, what contributes to error-producing conditions?
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What was the cause of the vincristine medication error reported?
What was the cause of the vincristine medication error reported?
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What approach does aviation take towards errors compared to healthcare?
What approach does aviation take towards errors compared to healthcare?
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Which aspect of human error does James Reason emphasize in his work?
Which aspect of human error does James Reason emphasize in his work?
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What outcome is deemed rare among highly trained professionals according to common misconceptions?
What outcome is deemed rare among highly trained professionals according to common misconceptions?
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What is a latent condition in the context of accident causation models?
What is a latent condition in the context of accident causation models?
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What was the primary error made by the nurse in the case of the patient who received naloxone?
What was the primary error made by the nurse in the case of the patient who received naloxone?
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Which strategy is recommended to reduce SALAD errors in prescribing medications?
Which strategy is recommended to reduce SALAD errors in prescribing medications?
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What was the effect of administering amiodarone instead of amantadine?
What was the effect of administering amiodarone instead of amantadine?
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How can healthcare professionals minimize the risk of errors related to drug names?
How can healthcare professionals minimize the risk of errors related to drug names?
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What additional information should be included on a prescription to enhance clarity?
What additional information should be included on a prescription to enhance clarity?
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What percentage range of medication errors occur during the prescribing stage?
What percentage range of medication errors occur during the prescribing stage?
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Which of the following contributed to the misadministration of methotrexate in The Cambridgeshire Enquiry?
Which of the following contributed to the misadministration of methotrexate in The Cambridgeshire Enquiry?
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What is the percentage of medication errors attributed to the administration stage?
What is the percentage of medication errors attributed to the administration stage?
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In The Cambridgeshire Enquiry, what was the ultimate outcome faced by the patient as a result of the medication error?
In The Cambridgeshire Enquiry, what was the ultimate outcome faced by the patient as a result of the medication error?
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Which phase of the medication-use process had the least percentage occurrence of errors according to the data presented?
Which phase of the medication-use process had the least percentage occurrence of errors according to the data presented?
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What is a primary factor contributing to medication errors according to the conclusions?
What is a primary factor contributing to medication errors according to the conclusions?
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Which component of the Prescribing Safety Assessment (PSA) is focused on patient engagement?
Which component of the Prescribing Safety Assessment (PSA) is focused on patient engagement?
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What is suggested as a means to improve the reporting rates of medication errors?
What is suggested as a means to improve the reporting rates of medication errors?
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Which quote reflects the importance of learning from errors in healthcare?
Which quote reflects the importance of learning from errors in healthcare?
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How can the multifactorial nature of medication errors be best summarized?
How can the multifactorial nature of medication errors be best summarized?
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What is one of the components of the medicines use process?
What is one of the components of the medicines use process?
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Which healthcare professional is primarily responsible for monitoring medication therapy?
Which healthcare professional is primarily responsible for monitoring medication therapy?
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What type of error was made by the GP in The Cambridgeshire Enquiry?
What type of error was made by the GP in The Cambridgeshire Enquiry?
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Which of the following best describes the role of pharmacists in the medication-use process?
Which of the following best describes the role of pharmacists in the medication-use process?
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Which stage is involved in the transcribing aspect of the medication-use process?
Which stage is involved in the transcribing aspect of the medication-use process?
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What is a critical aspect emphasized for safe medication use?
What is a critical aspect emphasized for safe medication use?
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What was the outcome of the prescribing error in The Cambridgeshire Enquiry?
What was the outcome of the prescribing error in The Cambridgeshire Enquiry?
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Which professional is NOT primarily involved in the dispensing phase of the medication-use process?
Which professional is NOT primarily involved in the dispensing phase of the medication-use process?
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What was the error rate reported for medication orders in the EQUIP study?
What was the error rate reported for medication orders in the EQUIP study?
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Which of the following is a common example of a prescribing error?
Which of the following is a common example of a prescribing error?
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In which situation is a prescribing error least likely to occur?
In which situation is a prescribing error least likely to occur?
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What percentage of prescriptions contained potentially lethal errors according to the findings?
What percentage of prescriptions contained potentially lethal errors according to the findings?
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Which of the following strategies is NOT recommended for risk management in prescribing?
Which of the following strategies is NOT recommended for risk management in prescribing?
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What is the role of pharmacists in the context of prescribing errors?
What is the role of pharmacists in the context of prescribing errors?
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Which group of doctors exhibited an error rate for prescriptions that was slightly lower than the overall study rate?
Which group of doctors exhibited an error rate for prescriptions that was slightly lower than the overall study rate?
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What approach should be taken when selecting the most appropriate medicine?
What approach should be taken when selecting the most appropriate medicine?
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What action did the nurse take upon discovering the incorrect dosage of methotrexate on the drug chart?
What action did the nurse take upon discovering the incorrect dosage of methotrexate on the drug chart?
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What was identified as a potential cause of the patient's deteriorating condition?
What was identified as a potential cause of the patient's deteriorating condition?
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What is the most critical error identified in the scenario concerning methotrexate dosage?
What is the most critical error identified in the scenario concerning methotrexate dosage?
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In the medication error statistics presented, which stage accounted for the second-highest percentage of errors?
In the medication error statistics presented, which stage accounted for the second-highest percentage of errors?
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What documented consequence resulted from the medication error involving methotrexate?
What documented consequence resulted from the medication error involving methotrexate?
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What was the primary reason for the patient's death in the case involving naloxone and Lanoxin?
What was the primary reason for the patient's death in the case involving naloxone and Lanoxin?
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Which of the following strategies is recommended to effectively reduce SALAD errors?
Which of the following strategies is recommended to effectively reduce SALAD errors?
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What specific prescribing practice is recommended to increase clarity and decrease errors?
What specific prescribing practice is recommended to increase clarity and decrease errors?
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What was the consequence of administering amiodarone instead of amantadine for the Parkinson's patient?
What was the consequence of administering amiodarone instead of amantadine for the Parkinson's patient?
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Which practice could help to address the issue of similar-sounding drug names during medication administration?
Which practice could help to address the issue of similar-sounding drug names during medication administration?
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What role does the community pharmacist play in the medication-use process during the prescribing phase?
What role does the community pharmacist play in the medication-use process during the prescribing phase?
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In The Cambridgeshire Enquiry, what was the consequence of the GP incorrectly prescribing methotrexate?
In The Cambridgeshire Enquiry, what was the consequence of the GP incorrectly prescribing methotrexate?
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Which group of healthcare professionals is NOT involved in the administering phase of the medication-use process?
Which group of healthcare professionals is NOT involved in the administering phase of the medication-use process?
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What aspect of medicine safety does the content emphasize regarding team involvement?
What aspect of medicine safety does the content emphasize regarding team involvement?
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According to the presented content, what is a key component of the medicines use process that is critical for error reduction?
According to the presented content, what is a key component of the medicines use process that is critical for error reduction?
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In which phase of the medication-use process would a GP likely identify the error made by the locum pharmacist?
In which phase of the medication-use process would a GP likely identify the error made by the locum pharmacist?
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What is a significant challenge highlighted in the medication-use process concerning complex prescriptions?
What is a significant challenge highlighted in the medication-use process concerning complex prescriptions?
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Which strategy is emphasized as effective in improving the safety and accuracy of the medication-use process?
Which strategy is emphasized as effective in improving the safety and accuracy of the medication-use process?
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What is a significant outcome of adopting a supportive safety culture in healthcare?
What is a significant outcome of adopting a supportive safety culture in healthcare?
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Which statement best reflects the complexity of medication errors?
Which statement best reflects the complexity of medication errors?
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According to the conclusions discussed, what is the primary reason for varying rates of medication errors?
According to the conclusions discussed, what is the primary reason for varying rates of medication errors?
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Which element is NOT a component of the Prescribing Safety Assessment (PSA)?
Which element is NOT a component of the Prescribing Safety Assessment (PSA)?
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What is the main focus of improving prescribing skills in relation to medication errors?
What is the main focus of improving prescribing skills in relation to medication errors?
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What is one of the significant factors that contributed to the error in Mrs. Moira Pullar's case?
What is one of the significant factors that contributed to the error in Mrs. Moira Pullar's case?
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What best practice should be followed when writing dosages to avoid misinterpretation?
What best practice should be followed when writing dosages to avoid misinterpretation?
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Which abbreviation has the potential to be mistaken for the number 10?
Which abbreviation has the potential to be mistaken for the number 10?
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In the context of error-prone abbreviations, what is the best expression for milliliters?
In the context of error-prone abbreviations, what is the best expression for milliliters?
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What common error can occur with the representation of the unit 'U'?
What common error can occur with the representation of the unit 'U'?
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Which practice is NOT recommended to minimize the risk of medication errors?
Which practice is NOT recommended to minimize the risk of medication errors?
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What is recommended to do with quantities of less than 1 gram?
What is recommended to do with quantities of less than 1 gram?
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Which of the following best illustrates the concept of 'sound-alike look-alike' drug errors?
Which of the following best illustrates the concept of 'sound-alike look-alike' drug errors?
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To ensure patient safety, what should be done when leading zeros are not present?
To ensure patient safety, what should be done when leading zeros are not present?
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What type of errors does the abbreviation 'ng' typically lead to when misinterpreted?
What type of errors does the abbreviation 'ng' typically lead to when misinterpreted?
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Study Notes
Medication Use Process
- The medication use process involves various stages: prescribing, transcribing, dispensing, administering, and monitoring.
- In a hospital setting, different healthcare professionals are involved at each stage.
- Doctors, pharmacists, nurses, and dieticians play crucial roles.
Prescribing Competency Framework
- The Cambridgeshire Enquiry highlighted a medication error involving methotrexate, leading to a patient's death.
- The incident revealed a series of failures across multiple stages of the medication use process.
- The inquiry emphasized the importance of robust prescribing practices and multidisciplinary collaboration.
Medication Error
- A medication error is defined as a preventable event that can lead to inappropriate medication use or harm to the patient.
- Studies indicate medication errors are most common during prescribing and administration, followed by transcribing and dispensing.
- The majority of errors occur during the prescribing stage, emphasizing the need for improved skills.
Prescribing Errors
- Common prescribing errors include incorrect dosing, drug interactions, illegible handwriting, and electronic prescribing errors.
Risk Management - Prescribing the Right Medicine
- Taking a comprehensive drug history is crucial to prevent errors, including prescription and over-the-counter medications, herbal remedies, and illicit drugs.
- Choosing the most appropriate medication involves utilizing resources like the BNF and guidelines, and seeking expert advice.
SALAD Errors
- SALAD errors stand for sound-alike/look-alike drugs, increasing the risk of medication errors.
- Pharmacies should avoid stocking medication with packaging prone to such errors, implementing a "purchase for safety policy."
Reason's Model of Accident Causation
- James Reason's model explains that accidents are often the result of a complex interaction of latent conditions and active failures.
- Latent conditions refer to underlying organizational processes, management decisions, and environmental factors.
- Active failures are errors or violations committed by individuals during the course of their work.
Vincristine Medication Error Case Report
- A tragic case involved the administration of vincristine intrathecally instead of intravenously, resulting in the patient's death.
- The incident highlights the importance of clear communication, familiar protocols, and robust safety checks to prevent such errors.
- The latent failure model can be modified from the original model to illustrate and analyze such medication errors.
Error Reduction Strategies
- Effective communication, collaboration, and shared learning are crucial for reducing medication errors.
- Strategies include implementing prescribing safety assessments (PSAs), utilizing drug information resources, and empowering patients to participate in their medication management.
Patient Empowerment for Medication Safety
- Patients are actively encouraged to engage in their medication safety by:
- Informing their healthcare providers about their complete medication history.
- Understanding their medications and potential risks.
- Reporting any concerns or adverse events.
Conclusions
- Medication errors are commonly preventable, and addressing them is paramount to patient safety.
- A supportive safety culture must be cultivated to encourage reporting medication errors and facilitate further investigation.
- Improving prescribing competency, communication, and collaboration is essential to minimize preventable harm.
Medication-Use Process
- The medication-use process includes prescribing, transcribing, dispensing, administering, and monitoring.
- Each stage involves multiple healthcare professionals, including doctors, pharmacists, nurses, and dieticians.
Prescribing Competency Framework
- The prescribing competency framework guides healthcare professionals in the safe and effective prescribing of medicines.
The Cambridgeshire Enquiry
- A woman with rheumatoid arthritis was prescribed methotrexate by her consultant, with her GP responsible for adjusting the dose.
- A series of prescribing errors occurred throughout the process, resulting in an incorrect dose being administered and contributing to the patient's death.
Medication Error
- A medication error is any preventable event that leads to inappropriate medication use or harm to the patient.
- Errors commonly occur during prescribing and administering medication, but they can also occur during transcribing and dispensing.
Prescribing Errors
-
Common Examples:
- Incorrect dosing.
- Drug interactions with other medications.
- Illegible handwriting on prescriptions.
- Electronic prescribing errors.
Risk Management - The Right Medication
- It is essential to take a full drug history from patients.
- This includes current prescriptions, non-prescription medications, herbal remedies, illicit drugs, and any adverse drug reactions (ADRs) or allergies.
- Choose the most appropriate medication, using resources like the British National Formulary (BNF) and relevant guidelines.
Risk Management - Legibility
- Handwritten prescriptions can lead to errors due to illegible handwriting.
- Use clear, complete drug names to avoid confusion.
- Specific doses should always be written, avoiding generic terms like "as directed."
Risk Management - Abbreviations
- Never abbreviate medication names.
- Abbreviations can lead to confusion and misinterpretation.
- Ensure clear communication and accurate dispensing of medication.
Error Reduction Strategies
-
Prescribing Safety Assessment (PSA):
- A 120-minute assessment tool with eight sections covering aspects of prescribing safety, including drug monitoring, adverse drug reactions, and patient empowerment.
Patient Empowerment for Medication Safety
- Patients should be actively involved in their medication safety by:
- Understanding the risks and benefits of their medicines.
- Reporting any concerns or adverse effects promptly.
- Taking an active role in managing their medication use.
Conclusions
- Medication errors are a preventable cause of patient injury.
- Most medication errors occur due to inadequate prescribing practices.
- A supportive safety culture is crucial to improve reporting and address the causes of preventable harm.
Patient Safety and Medicines
- Key quote: "To err is human, to cover up is unforgivable but to fail to learn is inexcusable." (Sir Liam Donaldson, World Health Organisation, 2004).
- Continuous learning and improvement are essential for medication safety.
Medication Use Process
- The medication use process involves prescribing, transcribing, dispensing, administering, and monitoring
- In a hospital setting, the process involves doctors, pharmacists, nurses, and sometimes dieticians
- There are specific roles for each of those professions at each step of the process
Prescribing Competency Framework
- The Cambridgeshire Enquiry is a real-life example of how medication errors can occur
- The enquiry highlighted a series of mistakes resulting in a patient's death due to a medication error
- The mistakes involved misinterpretations, poor communication, system failures, and lack of follow-up
Medication Error
- A medication error is an event that could cause or lead to inappropriate medication use or patient harm
- They can occur at any stage of the medication use process
- Studies suggest prescribing and administration stages have the highest occurrences of medication errors
Case Study: Mrs. Moira Pullar
- Mrs. Pullar died after being administered ten times too much insulin due to a medication error
- The error involved poor handwriting by the prescriber, failure of nurses and doctors to check the dosage and monitor the patient, and unclear prescription charting
- The case highlights the importance of clear and accurate record-keeping and the need for robust safety measures to prevent such tragedies
Risk Management: Abbreviations
- Abbreviations should be avoided as they can be misinterpreted, potentially leading to errors
- Examples include "IU" (International Unit) mistaken for IV (intravenous) or "l" (liter) mistaken for the number 1
- It is recommended to use full terms and avoid unnecessary decimal points, especially trailing zeros
Dispensing & Administration Errors
- Dispensing and administration errors can occur due to sound-alike and look-alike drugs (SALADS)
- These errors can be mitigated by using the full drug name on prescriptions and labels
- "Tall man" lettering can be used to highlight key differences in SALAD names
Risk Management: Numerals
- Using numerals can reduce medication errors as they are less prone to misinterpretation
- For example, writing "2mg" instead of "two mg" can prevent confusion
Error Reduction Strategies
- Strategies to reduce medication errors include using prescribing safety assessments (PSA), patient empowerment, and fostering a culture of safety
- PSA involves a structured approach to prescribing, including review, planning, management, and patient information
- Patient empowerment fosters a supportive environment where patients actively participate in their medication management
Patient Empowerment for Medication Safety
- Patients play a crucial role in medication safety
- They should be encouraged to ask questions, understand their medications, and report any concerns
- Empowering patients strengthens their role in medication safety and improves overall outcomes
Conclusions
- Medication errors are a preventable cause of patient harm
- Errors are often rooted in poor prescribing practices, highlighting the need for improved prescribing skills
- A multidisciplinary approach to medication safety and a supportive safety culture are essential to reduce medication errors and learn from them
Patient Safety and Medicines
- Preventing medication errors requires a commitment to continuous learning and improvement
- Fostering a culture of openness and accountability is essential for reporting and learning from medication errors
- "To err is human, to cover up is unforgivable but to fail to learn is inexcusable." - Sir Liam Donaldson, World Health Organisation (2004)
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Description
Test your knowledge on the medication use process, including stages like prescribing and administering. Explore the roles of healthcare professionals and the impact of medication errors highlighted by significant inquiries. Understand the importance of robust practices and collaborative efforts in preventing such errors.
