WHAT are medication errors?
|
|
- Matilda Maxwell
- 6 years ago
- Views:
Transcription
1 Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. Office Houston, TX Healthcare Case Study WHAT are errors? errors are preventable events that lead to s being used inappropriately. errors that cause harm are called adverse drug events. drug dose patient time rate preparation route of administration Copyright ThinkReliability 1
2 Healthcare Case Study: Errors Impacts of Errors Preventable adverse drug events in hospitals are estimated to injure hundreds of thousands of people and cost >$37B per year in the US. Per Institute of Medicine, a hospital patient can expect on average to be subjected to more than one error per day. Death or serious disability associated with a error is a never event (National Quality Forum) NHS Never Events Mis-selection of a strong potassium containing solution (rather than an intended different ) route administration of Intravenous chemotherapy via the intrathecal route Oral/enteral or feed/flush by an parenteral route Intravenous administration of a medicine intended to be via the epidural route Copyright ThinkReliability 2
3 Healthcare Case Study: Errors NHS Never events (cont.) Overdose of insulin due to abbreviations or incorrect device Overdose of methotrexate for non-cancer treatment Mis-selection of high strength midazolam during conscious sedation Canadian Safety Institute Never Events death or serious harm due to a failure to inquire whether a patient has a known allergy to, or due to administration of a where a patient s allergy had been identified. Copyright ThinkReliability 3
4 Healthcare Case Study: Errors Canadian Safety Institute Never Events (cont.) death or serious harm as a result of one of five pharmaceutical events -route administration of chemotherapy agents Intravenous administration of concentrated potassium solution Inadvertent injection of epinephrine intended for topical use Overdose of hydromorphone by administration of a higher-concentrated solution than intended Neuromuscular blockade without sedation, airway control and ventilation capability NOW WHAT do we do to reduce patient risk? Review administration process Causes of errors Case studies Copyright ThinkReliability 4
5 Healthcare Case Study: Errors Delivery Process Delivery Process prescribed transcribed prepared to patient Physician Pharmacist Nurse Process Map Prescribed/ Transcribed dose selected not informed about Physician determines patient need for Physician selects Physician selects dose Physician writes/ enters prescription Physician explains prescription to patient selected / dose written/ entered Copyright ThinkReliability 5
6 Healthcare Case Study: Errors Process Map Prepared/ Administered dose selected /dose route/ timing not monitored Pharmacist selects Pharmacist measures labeled delivered to patient to patient monitored selected / dose labeled given to wrong patient Errors Error Reporting Errors by Stage Administering 38% Prescribing 39% Dispensing 11% Transcribing 12% Copyright ThinkReliability 6
7 Healthcare Case Study: Errors New study: Pharmacy Errors Study of >1.8M orders at medical center in Texas found the following error rates per 100 shifts: 2.58 for verified orders per shift 8.44 for verified orders per shift for >400 verified orders per shift Overall error rate is 4.87 errors per 100,000 verified orders Case study 1: Infant Heparin Overdoses Step 1. Outline What When Where Impact to the Goals Problem(s) Date Time Different, unusual, unique Facility, site Unit, area, equipment Task being performed Safety Compliance Services Labor/ Time Adult heparin dose given to 6 newborns September 16, 2006? Saturday; dose 1000x higher Indianapolis, IN NICU Administration of heparin (blood thinner) 3 fatalities, premature newborns 3 critical condition premature newborns Never event Incorrect drug dose delivery Investigation Frequency 16,000 incorrect dosing errors between Copyright ThinkReliability 7
8 Healthcare Case Study: Errors Heparin Overdoses Heparin to infants Safety Goal Impacted 3 infant fatalities, 3 critical injuries dosage heparin dosage removed from bottle checks ineffective Heparin Overdoses Heparin to infants Used to prevent blood clots Risk of clogging intravenous (IV) tubes Drugs, food, water via IV Copyright ThinkReliability 8
9 Healthcare Case Study: Errors Heparin Overdoses Heparin to infants Safety Goal Impacted 3 infant fatalities, 3 critical injuries dosage heparin dosage removed from bottle checks ineffective Heparin Overdoses dosage removed from bottle dosage removed from cabinet dosage in cabinet dosage removed from pharmacy 10 unit/10,000 unit bottles look similar checks ineffective Copyright ThinkReliability 9
10 Healthcare Case Study: Errors Heparin Overdoses Heparin to infants Safety Goal Impacted 3 infant fatalities, 3 critical injuries dosage heparin dosage removed from bottle checks ineffective Heparin Overdoses checks ineffective dose not verified Nurse accustomed to only one dose NICU stocks only one dose of heparin Copyright ThinkReliability 10
11 Healthcare Case Study: Errors Heparin Overdoses Step 3. Solutions dosage heparin Heparin to infants dosage removed from bottle Solution: Review check process checks ineffective Solution: Use saline to flush IVs Used to prevent blood clots dosage removed from cabinet dose not verified Risk of clogging intravenous (IV) tubes Drugs, food, water via IV dosage in cabinet Nurse accustomed to only one dose Solution: Computer delivery system dosage removed from pharmacy NICU stocks only one dose of heparin Solution: Redesign bottles 10 unit/10,000 unit bottles look similar checks ineffective Case study 2: Mistaken Administration of Paralytic Agent Step 1. Outline What When Where Problem(s) Date Time Different, unusual, unique Facility, site Unit, area, equipment Task being performed Impact to the Goals Safety Employee Compliance Services Labor/ Time death, error December 1, 2014? Fire alarm (code red) at facility Bend, Oregon Hospital emergency room Administration of IV anti-seizure death 3 employees placed on administrative leave Never event not monitored after IV administration Investigation Frequency First time hospital has had issue like this Copyright ThinkReliability 11
12 Healthcare Case Study: Errors Paralytic Agent Administration Safety Goal Impacted death Cardiac arrest/ brain damage stopped breathing paralyzing agent via IV Evidence: Rocuronium Delay in treatment/ response not monitored after IV Paralytic Agent Administration prescribed anti-seizure Evidence: Fosphenytoin Sought treatment in ER paralyzing agent via IV put in IV bag Error in pharmacy IV bag marked for prescribed (correct) drug Copyright ThinkReliability 12
13 Healthcare Case Study: Errors Paralytic Agent Administration Safety Goal Impacted death Cardiac arrest/ brain damage stopped breathing paralyzing agent via IV Evidence: Rocuronium Delay in treatment/ response not monitored after IV Paralytic Agent Administration Staff unavailable Fire alarm went off not monitored after IV * Evidence: For ~20 minutes, per staff s door closed Protection from potential fire hazards *The hospital has determined that the patient not being monitored was not a causative factor in the patient s death. Copyright ThinkReliability 13
14 Healthcare Case Study: Errors Paralytic Agent Administration Step 3. Solutions Solution: Add alert stickers to paralytic agents paralyzing agent via IV prescribed anti-seizure Evidence: Fosphenytoin put in IV bag Sought treatment in ER Solution: Update protocols; implement detailed checking process & safety zone for verification Error in pharmacy IV bag marked for prescribed (correct) drug NOW WHAT Identify possible improvements to process Minimize distractions Add a double check Alerts/ guides for high risk Remember the 5 Rights of safety: Right Right dose Right time Right route Right patient Copyright ThinkReliability 14
15 Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. Office Houston, TX Healthcare Case Study Resources Comprehensive guide to safety: Causes of administration errors in hospitals (human behavior category based): Pharmacy study: California study (error rates in process): /PDF/PDF%20A/PDF%20addressingmederrorsframework. pdf Copyright ThinkReliability 15
Medicines Optimisation Patient Safety And Medication Safety. Dr David Cousins Associate Director Medication Safety and Medical Devices
Medicines Optimisation Patient Safety And Medication Safety Dr David Cousins Associate Director Medication Safety and Medical Devices The key elements of medicines optimisation is patient centred; makes
More informationMedication Errors in Chemotherapy PORSCHA L. JOHNSON, PHARM.D. CLINICAL PHARMACIST II MEDSTAR WASHINGTON HOSPITAL CENTER SATURDAY, SEPTEMBER 17, 2016
Medication Errors in Chemotherapy PORSCHA L. JOHNSON, PHARM.D. CLINICAL PHARMACIST II MEDSTAR WASHINGTON HOSPITAL CENTER SATURDAY, SEPTEMBER 17, 2016 DISCLOSURE STATEMENT I have nothing to disclose regarding
More informationRecommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018
Recommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018 January 2018 We support providers to give patients safe, high quality, compassionate care within
More informationTo prevent harm to patients from adverse medication events involving high-alert medications.
TITLE MANAGEMENT OF HIGH-ALERT MEDICATIONS DOCUMENT # PS-46-01 PARENT DOCUMENT LEVEL LEVEL 1 PARENT DOCUMENT TITLE Management of High-alert Medications Policy APPROVAL LEVEL Alberta Health Services Executive
More informationNever Events in Healthcare
Never Events in Healthcare Raising awareness to protect patients from serious harm or death September 11, 2015 The 4 th International Medication Safety Summit Conference Beijing, China Lindsay Yoo, BScPhm,
More informationREVISED FIP BASEL STATEMENTS ON THE FUTURE OF HOSPITAL PHARMACY
REVISED FIP BASEL STATEMENTS ON THE FUTURE OF HOSPITAL PHARMACY Approved September 2014, Bangkok, Thailand, as revisions of the initial 2008 version. Overarching and Governance Statements 1. The overarching
More informationSafe Medication Practices
Safe Medication Practices Patient Safety: Preventing Adverse Events OHA Conference Renaissance Toronto Hotel at SkyDome Toronto June 14, 2004 David U President & CEO, ISMP Canada Agenda ISMP Canada Patient
More informationFIRST PATIENT SAFETY ALERT FROM NATIONAL PATIENT SAFETY AGENCY (NPSA) Preventing accidental overdose of intravenous potassium
abcdefghijklm Health Department St Andrew s House Regent Road Edinburgh EH1 3DG MESSAGE TO: 1. Medical Directors of NHS Trusts 2. Directors of Public Health 3. Specialists in Pharmaceutical Public Health
More informationDrug Events. Adverse R EDUCING MEDICATION ERRORS. Survey Adapted from Information Developed by HealthInsight, 2000.
Survey Adapted from Information Developed by HealthInsight, 2000. Adverse Drug Events R EDUCING MEDICATION ERRORS The Adverse Drug Events Survey will assist healthcare organizations evaluate the number
More informationWrong route administration of an oral drug into a vein
Publication Ref: I2017/009/1 Wrong route administration of an oral drug into a vein 19 February 2018 This interim bulletin contains facts which have been determined up to the time of issue. It is published
More informationPOLICY. Clinician is any health care professional accepting responsibility for care of patients and their medications.
POLICY Number: 7311-60-020 Title: HIGH ALERT MEDICATIONS IDENTIFICATION, DOUBLE CHECK AND LABELING Authorization [ ] President and CEO [X ] Vice President, Finance and Corporate Services Source: Chair,
More informationDepartment Policy. Code: D: MM Entity: Fairview Pharmacy Services. Department: Fairview Home Infusion. Manual: Policy and Procedure Manual
Department Policy Code: D: MM-5615 Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Chemotherapy Purpose: Ensure
More informationMedication Administration & Preventing Errors M E A G A N R A Y, R N A M G S P E C I A L T Y H O S P I T A L
Medication Administration & Preventing Errors M E A G A N R A Y, R N A M G S P E C I A L T Y H O S P I T A L Principles of Medication Administration Talk with the patient and explain what you are doing
More informationMartina Khundakar - Senior Clinical Pharmacist Teresa Barnes - Lead Clinical Pharmacist - Specialist Care. Timothy Donaldson, Trust Chief Pharmacist
Policy on Pharmacological Therapies Practice Guidance Note The use of Oral Anti-Cancer Medicines and Oral Methotrexate within - V03 V03 - Issued Issue 1 Dec 15 Planned review December 2018 PPT-PGN 09 Part
More informationSharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use
Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use Our vision is to create a culture where patients and those who care for them are
More informationNurse Orientation. Medication Management
Nurse Orientation Medication Management Objectives Discuss basic principles/rights of medication administration, according to your site policy Describe principles of patient/family education related to
More informationAnatomy of a Fatal Medication Error
Anatomy of a Fatal Medication Error Pamela A. Brown, RN, CCRN, PhD Nurse Manager Pediatric Intensive Care Unit Doernbecher Children s Hospital Objectives Discuss the components of a root cause analysis
More informationCurrent Status: Active PolicyStat ID:
Current Status: Active PolicyStat ID: 2002682 Origination: 05/2005 Last Approved: 02/2014 Last Revised: 02/2014 Next Review: 01/2017 Owner: Policy Area: References: Chase Walters: Director, Education Patient
More information8/24/2015. Paralyzing Danger: Safety Strategies for Neuromuscular Blocking Agents. How NMBs Work. NMB Prototype: Curare. Clinical Use Today
Paralyzing Danger: Safety Strategies for Neuromuscular Blocking Agents Peggy Bickham, PharmD Assistant Director Hospital Pharmacy Specialty and Support Services University of Illinois Hospital Chicago,
More informationNursing Home Medication Error Quality Initiative
Nursing Home Medication Error Quality Initiative MEQI Report: Year Five October 1, 2007 to September 30, 2008 MEQI A report on the fifth year of mandatory reporting of medication errors for all state licensed
More informationMedication Management Policy and Procedures
POLICY STATEMENT This policy establishes guidelines for ensuring safe and correct management of client medications in accordance with legislative and regulatory requirements and professional practice competency
More informationD DRUG DISTRIBUTION SYSTEMS
D DRUG DISTRIBUTION SYSTEMS JANET HARDING ORAL MEDICATION SYSTEMS Drug distribution systems in the hospital setting should ideally prevent medication errors from occurring. When errors do occur, the system
More informationINQUEST INTO THE DEATH OF: MARIE TANNER
INQUEST INTO THE DEATH OF: MARIE TANNER Details Name of Deceased: Marie Tanner Date of Death: January 21, 2002 Place of Death: Peterborough Regional Health Centre Cause of Death: Cardiac Arrest Caused
More informationThanks to Anne C. Byrne, RN, Medical Monitor at Northwest Georgia Regional Hospital. This presentation was developed from one she designed for that
Thanks to Anne C. Byrne, RN, Medical Monitor at Northwest Georgia Regional Hospital. This presentation was developed from one she designed for that hospital. 1 2 3 Note that an actual variance occurs when
More information5. returning the medication container to proper secured storage; and
111-8-63-.20 Medications. (1) Self-Administration of Medications. Residents who have the cognitive and functional capacities to engage in the self-administration of medications safely and independently
More informationFive Rights of Medication
Five Rights of Medication Lack of knowledge has been implicated in many medication errors; therefore, education about broadly stated goals and practices to safely administer medications is essential. Medication
More informationThe Multidisciplinary aspects of JCI accreditation
The Multidisciplinary aspects of JCI accreditation Saleem Kiblawi MD, FCCP, Physician consultant, Joint Commission International Oakbrook, Illinois USA Lebanese American University April 15, 2016 Beirut,
More informationLicensed Pharmacy Technicians Scope of Practice
Licensed s Scope of Practice Adapted from: Request for Regulation of s Approved by Council April 24, 2015 DEFINITIONS In this policy: Act means The Pharmacy and Pharmacy Disciplines Act means an unregulated
More informationNHS HDL (2002) 22 abcdefghijklm
NHS HDL (2002) 22 abcdefghijklm Health Department Dear Colleague SAFE ADMINISTRATION OF INTRATHECAL CYTOTOXIC CHEMOTHERAPY Purpose This circular provides Guidance on the Safe Administration of Intrathecal
More informationManagement of Reported Medication Errors Policy
Management of Reported Medication Errors Policy Approved By: Policy & Guideline Committee Date of Original 6 October 2008 Approval: Trust Reference: B45/2008 Version: 4 Supersedes: 3 February 2015 Trust
More informationASA Standards of Practice for Injection of Local Anesthetics
ASA Standards of Practice for Injection of Local Anesthetics Adopted by BOD March 2014 Introduction The following Standards of Practice were researched and authored by the ASA Education and Professional
More informationMedication Safety in the Operating Room: Using the Operating Room Medication Safety Checklist
Medication Safety in the Operating Room: Using the Operating Room Medication Safety Checklist CPSI Safe Surgery Saves Lives Workshop Montréal, QC 29Mar2011 Julie Greenall, RPh, BScPhm, MHSc, FISMPC Institute
More informationMedication Management and Use. Anadolu Medical Center. August, Departman Tarih
Medication Management and Use Anadolu Medical Center August, 2014 Departman Tarih Medication Management and Use standards (MMU) Organization and Management 1. Medication use in the hospital is organized
More informationAdverse Drug Events: A Focus on Anticoagulation Steve Meisel, Pharm.D., CPPS Director of Patient Safety Fairview Health Services, Minneapolis, MN
Adverse Drug Events: A Focus on Anticoagulation Steve Meisel, Pharm.D., CPPS Director of Patient Safety Fairview Health Services, Minneapolis, MN Fairview Health Services 6 hospitals, ranging from rural
More informationAdministration of Intrathecal Cytotoxic Chemotherapy in NHS Grampian
Administration of Intrathecal Cytotoxic Chemotherapy in NHS Grampian Lead Author/Coordinator: Jeff Horn / Sarah Howlett Macmillan Haematology CNS/ Pharmacist Reviewer: Gavin Preston Consultant Haematologist
More informationCIVAS IN SWITZERLAND 2002
CIVAS IN SWITZERLAND 2002 William Griffiths Pharmacy September 13th, 2002 Lugano, Switzerland. William Griffiths, Pharmacie des HUG, Lugano sept. 2002 1 INTRODUCTION HOSPITAL PHARMACY General orientation
More informationOverview. Diane Cousins, R.Ph U.S. Pharmacopeia. 1 Pharmacy Labeling with Color
As more medications are approved and become available to Americans, the opportunity for potentially dangerous or even deadly errors due to drug mix-ups from look alike or sound alike names becomes increasingly
More informationabcdefghijklmnopqrstu
Health Directorates Healthcare Planning and Policy Dear Colleague SAFE ADMINISTRATION OF INTRATHECAL CYTOTOXIC CHEMOTHERAPY Purpose This circular provides revised guidance on the Safe Administration of
More informationSELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING
CLINICAL PROTOCOL SELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING RATIONALE Medication errors can cause unnecessary
More informationMedication Storage and Security: The #1 Non- Complaint Medication Management Standard
Learning Objectives and Security: The #1 Non- Complaint Medication Management Standard d Manager, Army Patient Safety Program U.S. Army Medical Command Fort Sam Houston, TX Describe the importance of maintaining
More informationTHE TEXAS GUIDE TO SCHOOL HEALTH PROGRAMS 251
THE TEXAS GUIDE TO SCHOOL HEALTH PROGRAMS 251 Exhibit 1: Skills Checklist for Medication Administration Person trained: Position: Instructor: Type of Medication Administration (Oral, Topical etc.): (*See
More informationMedication Guidelines
Guidelines March 2015 Medication Guidelines MEDICATION MARCH 2015 i Approved by the College and Association of Registered Nurses of Alberta () Provincial Council, March 2015. On September 22, 2017 Provincial
More informationSARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY
PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: NURSING AND PHARMACY GUIDELINES FOR THE ADMINISTRATION OF IV TREPROSTINIL (REMODULIN ) Job Title of Reviewer: Director, Pharmacy POLICY
More informationAPPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS
APPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS Use the following checklists in the appropriate areas of your office, facility or practice to assist in preventing medications errors:
More informationClinical Check of Prescriptions in Ward Areas
Pharmacy Department Standard Operating Procedures SOP Title Clinical Check of Prescriptions in Ward Areas Author name and Gareth Price designation: Deputy Director of Pharmacy Clinical Services Pharmacy
More informationTexas Administrative Code
RULE 19.1501 Pharmacy Services A licensed-only facility must assist the resident in obtaining routine drugs and biologicals and make emergency drugs readily available, or obtain them under an agreement
More informationCRAIG HOSPITAL POLICY/PROCEDURE
CRAIG HOSPITAL POLICY/PROCEDURE Approved: P&T, MEC, NPC, P&P 03/09 Effective Date: 02/95 P&T, MEC, P&P 08/09; P&P 08/10; P&T, MEC 10/10, P&T, P&P 12/10 ; MEC 01/11; P&T, MEC 02/11, 04/11 ; P&T, P&P 12/11
More informationSystemic anti-cancer therapy Care Pathway
Network Guidance Document Status: Expiry Date: Version Number: Publication Date: Final July 2013 V2 July 2011 Page 1 of 9 Contents Contents... 2 STANDARDS FOR PREPARATION AND PHARMACY... 3 1.1 Facilities
More informationU: Medication Administration
U: Medication Administration Alberta Licensed Practical Nurses Competency Profile 199 Competency: U-1 Pharmacology and Principles of Administration of Medications U-1-1 U-1-2 U-1-3 U-1-4 Demonstrate knowledge
More informationMEDCOM Medication Management Discussion
MEDCOM Medication Management Discussion 2009 MEDCOM-TJC Conference Manager, Army Patient Safety Program Quality Management Office HQ, US Army Medical Command Fort Sam Houston, TX 19 Nov 2009 BRIEFING OUTLINE
More informationNever Events LISA Matt Provost
Never Events LISA 2017 Matt Provost mattpro@yelp.com/@hypersupermeta Yelp s Mission Connecting people with great local businesses. History of the NHS World s first universal health care system - June 1948
More informationA Discussion of Medication Error Reduction Strategies
A Discussion of Medication Error Reduction Strategies By: Donald L. Sullivan, R.Ph., Ph.D. Program Number: 071067-011-01-H05 C.E.U.s: 0.1 Contact Hours: 1 hour Release Date: 4/1/11 Expiration Date: 4/1/14
More informationStorage, Labeling, Controlled Medications Instructor s Guide CFR (b)(2)(3)(d)(e) F431
Centers for Medicare & Medicaid Services (CMS) Storage, Labeling, Controlled Medications Instructor s Guide CFR 483.60(b)(2)(3)(d)(e) F431 2006 Prepared by: American Institutes for Research 1000 Thomas
More informationThe Joint Commission Medication Management Update for 2010
Learning Objectives The Joint Commission Medication Management Update for 2010 U.S. Army Medical Command Fort Sam Houston, TX Describe most recent changes in The Joint Commission (TJC) Accreditation Program
More informationObjectives MEDICATION SAFETY & TECHNOLOGY. Disclosure. How has technology improved the way we dispense and compound medications AdminRx AcuDose Rx
MEDICATION SAFETY & TECHNOLOGY Objectives Identify technology that can improve medication safety and decrease medication errors Identify ways that technology can cause medication errors if used inappropriately
More informationSHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE MEDICATION ERRORS
MEDICATION ERRORS Patients depend on health systems and health professionals to help them stay healthy. As a result, frequently patients receive drug therapy with the belief that these medications will
More informationPolicy Statement Medication Order Legibility Medication orders will be written in a manner that provides a clearly legible prescription.
POLICY POLICY PURPOSE: The purpose of this policy is to provide a foundation for safe communication of medication and nutritional orders in-scope, thereby reducing the potential for preventable medication
More informationProcedure For Taking Walk In Patients
Procedure For Taking Walk In Patients 1. Welcome customers and accept prescription(s) from them. All Staff 2. Ensure that the patients personal details are correct and legible To ensure correct details
More information2. Short term prescription medication and drugs (administered for less than two weeks):
Medication Administration Procedure This is a companion document with Policy # 516 Student Medication To access the policy: click on Policies (under the District Information heading) The Licensed School
More informationNorth West Residential Support Services Inc. Policies & Procedures PROCEDURES FOR THE ADMINISTRATION OF MEDICATION IN SHARED HOMES
North West Residential Support Services Inc. Policies & Procedures PROCEDURES FOR THE ADMINISTRATION OF MEDICATION IN SHARED HOMES Number: Effective From: Replaces: Review: NWRSS
More information10/4/2012. Disclosure. Leading a Meaningful Event Investigation. Just Culture definition. Objectives. What we all have in common
Leading a Meaningful Event Investigation Natasha Nicol, Pharm D, FASHP Director, Medication Safety Cardinal Health Disclosure I do not have a vested interest in or affiliation with any corporate organization
More informationManaging medicines in care homes
Managing medicines in care homes http://www.nice.org.uk/guidance/sc/sc1.jsp Published: 14 March 2014 Contents What is this guideline about and who is it for?... 5 Purpose of this guideline... 5 Audience
More informationSTANDARD OPERATING PROCEDURE ADMINISTRATION OF HEPARIN FLUSHES VIA CENTRAL INTRAVENOUS ACCESS DEVICES
STANDARD OPERATING PROCEDURE ADMINISTRATION OF HEPARIN FLUSHES VIA CENTRAL INTRAVENOUS ACCESS DEVICES First Issued Issue Version One Purpose of Issue/ Description of Change To promote the safe administration
More informationMeeting the NEW RCN Standards for Infusion Therapy in practice
Meeting the NEW RCN Standards for Infusion Therapy in practice sumanshrestha@nhs.net Suman Shrestha MSc BSc RN Advanced Nurse Practitioner Intensive Care Frimley Park Hospital suman_sr FRIMLEY PARK HOSPITAL
More informationMEDICATION ADMINISTRATION: BELOW THE DRIP CHAMBER
KINGSTON GENERAL HOSPITAL MEDICATION ADMINISTRATION: BELOW THE DRIP CHAMBER LEARNING GUIDE FOR REGISTERED NURSES AND REGISTERED PRACTICAL NURSES Prepared by: Nursing Education Date: 2001 November Revised:
More information3/9/2010. Objectives. Pharmacist Role in Medication Safety and Regulatory Compliance
Pharmacist Role in Medication Safety and Regulatory Compliance Janet Greiwe Vice President, Systems Management Cleveland County Health System Objectives By the end of this presentation, you should be able
More information201 KAR 20:490. Licensed practical nurse intravenous therapy scope of practice.
201 KAR 20:490. Licensed practical nurse intravenous therapy scope of practice. RELATES TO: KRS 314.011(10)(a), (c) STATUTORY AUTHORITY: KRS 314.011(10)(c), 314.131(1), 314.011(10)(c) NECESSITY, FUNCTION,
More informationPURPOSE To establish a standardized process for the activity of an independent double check for medication administration.
PURPOSE To establish a standardized process for the activity of an independent double check for medication administration. POLICY STATEMENTS Health Care Providers will complete the independent double check
More informationEnsuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING
Ensuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING Contents Page 1.0 Purpose 2 2.0 Definition of medication error
More informationDisclosure. Institute of Medicine (IOM) 1,2. Objectives 5/15/2014. Technician Education Day May 24, 2014 Ft. Lauderdale, FL
Technician Education Day May 24, 2014 Ft. Lauderdale, FL The Pharmacy Technician s Role in Keeping Our Patients Safe Antonia Zapantis, MS, PharmD, BCPS Associate Professor, Nova Southeastern University
More informationMedication Safety & Electrolyte Administration. Objectives. High Alert Medications. *Med Safety Electrolyte Administration
Medication Safety & Electrolyte Administration Jennifer Doughty, PharmD PGY2 Pharmacy Resident Emergency Medicine Stormont Vail Health, Topeka, KS Objectives Define and identify high alert medications
More information5th International Conference on Well-Being in the Information Society, WIS 2014, Turku, Finland, August 18-20, 2014
5th International Conference on Well-Being in the Information Society, WIS 2014, Turku, Finland, August 18-20, 2014 EVALUATION OF INTRAVENOUS MEDICATION ERRORS WITH INFUSION PUMPS Eija Kivekäs, MSc, RN,
More informationMcMinnville School District #40
McMinnville School District #40 Code: JHCD/JHCDA-AR Adopted: 1/08 Revised/Readopted: 8/10; 2/14; 2/15 Orig. Code: JHCD/JHCDA-AR Prescription/Nonprescription Medication Students may, subject to the provisions
More informationEnsuring Safe & Efficient Communication of Medication Prescriptions
Ensuring Safe & Efficient Communication of Medication Prescriptions in Community and Ambulatory Settings (September 2007) Joint publication of the: Alberta College of Pharmacists (ACP) College and Association
More informationPHARMACEUTICALS AND MEDICATIONS
DESCHUTES COUNTY ADULT JAIL CD-10-17 L. Shane Nelson, Sheriff Jail Operations Approved by: December 6, 2017 POLICY. PHARMACEUTICALS AND MEDICATIONS It is the policy of Deschutes County Sheriff s Office
More informationMedication Safety in LTC. Objectives. About ISMP Canada
Medication Safety in LTC Part II -Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety Lynn Riley, RN ISMP Canada Thursday, October 20, 2011 Objectives At the end of
More informationTo describe the process for the management of an infusion pump involved in an adverse event or close call.
TITLE INFUSION PUMPS FOR MEDICATION & PARENTERAL FLUID ADMINISTRATION SCOPE Provincial, Clinical DOCUMENT # PS-70-01 APPROVAL LEVEL Executive Leadership Team SPONSOR Provincial Medication Management Committee
More informationMedication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety
Medication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety Background The Institute of medicine (IOM) estimates that 1.5 million preventable Adverse Drug Events (ADE) occur
More informationDISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO. PANEL: Joanne Furletti, RN Chairperson Rosalie Woods, RPN Member
DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: Joanne Furletti, RN Chairperson Rosalie Woods, RPN Member Gino Cucchi Public Member John Bald Public Member BETWEEN: COLLEGE OF NURSES OF
More informationElectronic Medication Administration Process and Tips
Updated: December 2003 This document summarizes the exact steps to be followed as you administer and chart meds using the emar. Step 1: Check and review all new orders Select the Orders chart tab, click
More informationN ATIONAL Q UALITY F ORUM. Safe Practices for Better Healthcare 2006 Update A CONSENSUS REPORT
N ATIONAL Q UALITY F ORUM Safe Practices for Better Healthcare 2006 Update A CONSENSUS REPORT NATIONAL QUALITY FORUM Foreword Every person who seeks care in a healthcare facility should expect to receive
More informationADMINISTRATION OF MEDICATION BY DELEGATION
ADMINISTRATION OF MEDICATION BY DELEGATION ROLE AND RESPONSIBILITY OF THE TEACHER TRAINING MANUAL Medication Training Manual Final 10-2-17 Page 1 of 17 MEDICATION ADMINISTRATION TRAINING OBJECTIVES UPON
More informationPenticton & District Community Resources Society. Child Care & Support Services. Medication Control and Monitoring Handbook
Penticton & District Community Resources Society Child Care & Support Services Medication Control and Monitoring Handbook Revised Mar 2012 Table of Contents Table of Contents MEDICATION CONTROL AND MONITORING...
More informationC. Physician s orders for medication, treatment, care and diet shall be reviewed and reordered no less frequently than every two (2) months.
SECTION 1300 - MEDICATION MANAGEMENT 1301. General A. Medications, including controlled substances, medical supplies, and those items necessary for the rendering of first aid shall be properly managed
More informationNOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section.
TITLE MEDICATION ORDERS SCOPE Provincial APPROVAL AUTHORITY Clinical Operations Executive Committee SPONSOR Provincial Medication Management Committee PARENT DOCUMENT TITLE, TYPE AND NUMBER Not applicable
More informationMAR/MEDICATION AUDIT NAME NAME NAME
MAR/MEDICATION AUDIT NAME NAME NAME DATE Copies of all current prescriptions in file (correlate with MAR, Meds on hand and Healthcare Communication Forms) MAR reflects current correct medications, correct
More information1. Guidance notes. Social care (Adults, England) Knowledge set for medication. What are knowledge sets? Why were knowledge sets commissioned?
Social care (Adults, England) Knowledge set for medication 1. Guidance notes What are knowledge sets? Part of the sector skills council Skills for Care and Development Knowledge sets are sets of key learning
More informationMedication Safety Way Beyond the 5 Rights
Safety Way Beyond the 5 Rights JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS The University of Pennsylvania Health System Philadelphia, PA Current State. Of Chaos Prescriptions 12 per /person / year 4 BILLION
More informationNEW JERSEY. Downloaded January 2011
NEW JERSEY Downloaded January 2011 SUBCHAPTER 29. MANDATORY PHARMACY 8:39 29.1 Mandatory pharmacy organization (a) A facility shall have a consultant pharmacist and either a provider pharmacist or, if
More informationPreventing Disasters in Your Practice
Preventing Disasters in Your Practice Medication Errors Kendall Egan MD, FAAD DermOne Wilmington NC Clinical Director Financial Disclosures I do not have any relevant financial disclosures. Outline Medication
More informationSafer use of anticoagulants: the NPSA patient safety alert Steve Chaplin MSc, MRPharmS
Safer use of anticoagulants: the NPSA patient safety alert Steve Chaplin MSc, MRPharmS Steve Chaplin describes the NPSA s anticoagulant patient safety alert and the measures it recommends for making the
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Injectable Medicines Policy
The Newcastle upon Tyne Hospitals NHS Foundation Trust Injectable Medicines Policy Version No.: 4.3 Effective From: 24 March 2017 Expiry Date: 21 January 2019 Date Ratified: 11 January 2017 Ratified By:
More information(10+ years since IOM)
Medication Errors We're Looking Down the Tunnel and Seeing Light (10+ years since IOM) Michael R. Cohen, RPh, MS, ScD Institute for Safe Medication Practices mcohen@ismp.org 1 Disclosure Information Michael
More informationPolicies and Procedures for LTC
Policies and Procedures for LTC Strictly confidential This document is strictly confidential and intended for your facility only. Page ii Table of Contents 1. Introduction... 1 1.1 Purpose of this Document...
More informationSupplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology
More informationMEDICATION SAFETY SELF-ASSESSMENT FOR LONG-TERM CARE ONTARIO SUMMARY. April 2009 September 2012
MEDICATION SAFETY SELF-ASSESSMENT FOR LONG-TERM CARE ONTARIO SUMMARY April 2009 September 2012 Institute for Safe Medication Practices Canada Institut pour l utilisation sécuritaire des médicaments du
More informationPreventing Adverse Drug Events and Harm
Preventing Adverse Drug Events and Harm Frank Federico, RPh, IHI Executive Director Steve Meisel, PharmD, IHI Faculty March 27th,2012 12:00-1:00pm ET Beth O Donnell, MPH Beth O Donnell, MPH, Institute
More informationAdvanced Practice Provider (APP): Nurse Practitioner (NP) or Physician s Assistant (PA).
GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: { } All DJJ Staff { } Administration { } Community Services {x} Secure Facilities (RYDC and YDC) Transmittal # 17-15 Policy # 11.26 Related Standards
More informationFollowing are some common questions and answers from the hospital perspective regarding Manufacturing and Compounding :
Health Canada Manufacturing and Compounding Drug Products in Canada: A Policy Framework : Guidelines for P.E.I. Community and Hospital Pharmacists October 2001 In response to pharmacists questions about
More informationSection 2 Medication Orders
Section 2 Medication Orders 2-1 Objectives: 1. List/recognize the components of a complete medication order. 2. Transcribe orders onto the Medication Administration Record (MAR) correctly use proper abbreviations,
More information