Study Set Content:
ADMINISTRATION ERROR includes:
In the preparation and administration of IV medicines on the ward.
Wrong route of administration, wrong equipment or using in wrong form e.g, needs to be dissolved or diluted.
Deviation from prescription or standard operating procedure.
PRESCRIBE MEDICATION
DISPENSE/SUPPLIES MEDICINE
ADMINISTER MEDICATION
MONITOR DEFECTS
poor handwriting, oral communication only, missing of misplaced zeroes, use of abbreviations, ambiguous or incomplete prescriptions
Communication Failures:
-(when used as intended), contra-indication to the use of the medicine in relation to drugs or conditions, mismatching between patient and medicine, omitted medicine/ingredient, patient allergic to treatment wrong/omitted/passed expiry date, wrong/omitted patient information leaflet, wrong/omitted verbal patient directions/ wrong/ transposed/ omitted medicine label, wrong/unclear dose or strength. Wrong drug/ medicine, wrong formulation, wrong frequency, wrong method of preparation/ supply, wrong quantity, wrong route, wrong storage
ADVERSE DRUG REACTION
Similar drug names or presentation (look alike sounds alike
Similar drug names or presentation (look alike sounds alike
Stress, team, design, workload and satisfaction
Workplace problems
Level of staffing, level of experience, calculation errors, frequent patient transition of care
Workplace problems
Complex or poorly designed technology, devices or procedures.
Workplace problems
Repeat prescribing and dispensing without monitoring
Communication Failures
Complex diseases or treatment plans, patients with chronic conditions
Complex diseases or treatment plans, patients with chronic conditions
Complex diseases or treatment plans, patients with chronic conditions
Workplace problems
Lack of patient’s understanding of their therapy
Workplace problems
“Serious, largely preventable patient safety incidents that should not occur if the available preventatives measure have been implemented by
healthcare providers.”
-is a pro-active approach to prevent future errors happening
NEAR-MISS REPORTING
is a fundamental part of a patient safety and improvement culture.
Error reporting
One to one education/training for medical, pharmacy students or registrars usually in forms of lectures on safe prescribing followed by workshop, test or osces, group education for qualified professionals, improvement programs, error monitoring & reporting
Education & Development
Expanding Professional Roles: Pharmacist involvement Tools:
Electronic Prescribing (ePrescribing), also known as Computerized Physician Order Entry (CPOE).
