(10+ years since IOM)

Size: px
Start display at page:

Download "(10+ years since IOM)"

Transcription

1 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 1

2 Disclosure Information Michael R. Cohen, RPh, MS, ScD has no financial relationships to disclose and will not discuss off label use and/or investigational use in this presentation. 2

3 Medication Safety Issues Culture of safety (blame and shame) Error reporting programs Quality issues Patient safety technology Product related issues

4 Heparin issues Recent high-profile reports of injury

5 Error Reporting Programs and Resulting Improvement Efforts B+

6 Patient Safety Act and Quality Improvement Act of 2005 Patient Safety Organizations

7 ISMP Medication Errors Reporting Program Operated by the Institute for Safe Medication Practices ISMP is a federally certified patient safety organization (PSO) Pennsylvania Patient Safety Reporting Program

8 Other reporting programs Maryland Patient Safety Center PSO Pennsylvania Patient Safety Authority VHA Center for Patient Safety/NASA New York Patient Occurrence and Tracking System (NYPORTS) Oregon Patient Safety Center MedMARx (medication errors)

9 Other government funded programs FDA MedWatch Web M and M (allows sharing of cases via Internet)

10 Medication Error Reporting System Early warning system Issue nationwide hazard alerts and press releases Learning Dissemination of information and tools Change Product nomenclature, labeling, and packaging changes, device design, practice issues Standards and Guidelines Advocates for national standards and guidelines

11 National Quality Forum Serious Reportable Events (SREs) Errors in medical care that are clearly identifiable, preventable, and serious in their consequences Examples: surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe pressure ulcer acquired in the hospital

12 National Quality Forum Serious Reportable Events (SREs) Errors in medical care that are clearly identifiable, preventable, and serious in their consequences Problem in the safety and credibility of a health care facility Examples: surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe pressure ulcer acquired in the hospital

13 The Joint Commission (TJC) Sentinel Event Reporting Program You can get much further with a kind word and a gun than you can with a kind word alone. Al Capone National Patient Safety Goals

14 JCAHO

15 NQF Safe Practices

16 Culture of safety C+

17 The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Lucian Leape

18 Safety Culture sins Focus on individuals Hindsight bias Reacting to emotional component of patient harm Failure to move beyond proximate causes Believing there is a single root cause Response confused with proactive risk management when actually reactive Tunnel vision (both causes and actions) Weak error reduction strategies

19 Culture of Safety Errors not a measure of competency Management style promote safety and Just Culture Value complainers Reward patient safety and reporting Encourage story telling Visible leadership (walk arounds) medication safety officer

20 ISMP top things to do to improve safety Be proactive, not reactive. Learn from experience of other organizations. Medication safety officer/team. Focus on unsafe practices/at risk behaviors (e.g., unlabelled containers, sharing insulin pens, abbreviating drug names, patient weight conversions, etc.) Implement technologies (smart pumps, bedside bar code scanning, follow automated dispensing cabinet guidelines, e-rx, etc.) Standardize drug concentrations, units of measure, etc. Encourage error reporting internal and external (see ISMP Med Safety Alert! Pump up the volume tips for increasing reporting. Feb 9,

21 Just Culture - The Three Behaviors Human Error Product of our current system design Manage through changes in: Processes Procedures Training Design Environment At-Risk Behavior Unintentional Risk-Taking Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Reckless Behavior Intentional Risk-Taking Manage through: Remedial action Disciplinary action Console Coach Punish

22 Two Disconnected Conversations No Blame Accountability

23 Criminal Charges for Medication Errors

24 ISMP top things to do to improve safety Be proactive, not reactive. Learn from experience of other organizations. Medication safety officer/team. Focus on unsafe practices/at risk behaviors (e.g., unlabelled containers, sharing insulin pens, abbreviating drug names, patient weight conversions, etc.) Implement technologies (smart pumps, bedside bar code scanning, follow automated dispensing cabinet guidelines, e-rx, etc.) Standardize drug concentrations, units of measure, etc. Encourage error reporting internal and external (see ISMP Med Safety Alert! Pump up the volume tips for increasing reporting. Feb 9,

25 Quality Issues B+

26

27 Hand Washing Typical hand hygiene rates circa 1999: 20-30% Public reporting of / no pay for/?lawsuits for HAIs: tremendous push to improve Many organizations now at 40-70%, and stuck It s a Systems Problem : Education, dispensers every 3 feet A systems problem? Really? Wachter, Pronovost. NEJM 10/1/09

28 Patient safety technology B

29

30 High Impact Do First Constraints on high alert drugs Limiting abbreviations Pocket drug reference Dedicated ICU Pharmacist Med Safety Officer Intervention database Unit dose dispensing Automated dispensing cabinets Smart pumps Investment Automated ADE monitoring CPOE Bar-coding Robotic dispensing Preprinted order forms Medication training Drug-food interactions Don t Bother Low Cost (Courtesy David Bates) High

31 Product safety B

32 Examples of the Impact Medication Error Reporting

33 US Food and Drug Administration PDUFA IV Nomenclature testing Package label requirements Device safety Patient safety news FDA-ISMP Fellowship Etc. Division of Medication Error Prevention and Analysis (DMEPA)

34 Look-alike and Sound-alike Drug Names

35

36

37 Leading Products in Harmful Medication Errors Generic Name n % Insulin* Morphine* Heparin* Fentanyl* Hydromorphone* Warfarin* Potassium Chloride* Vancomycin Enoxaparin* Metoprolol Tartrate Furosemide Methylprednisolone Meperidine* From MedMarx 2007 * = high alert

38 Problems associated with PCA Patient selection, assessment and monitoring Drug product mix-ups Human factors/design flaws Staff training, and competency assessment Order communication errors PCA by proxy Device-related issues

39 Risk Evaluation and Mitigation Strategies (REMS) 39

40

41

42 Look-alike product labeling

43 Slide 43

44

45

46

47 47 Current labeling

48

49 49 TALLman LETTering

50 Considerations with color on labels Potential for mix-ups within the class must be considered

51

52

53

54 Availability of medicines D-

55 Drug Shortages Clinical effects Adversely affect drug therapy Compromise or delay medical treatment/procedures Result in failure to treat and progression of disease Result in medication errors and adverse patient outcomes

56 Drug Shortages Financial effects of shortages Costly alternative medications for provider and patient Significant time spent on addressing shortages Additional costs associated with treatment of adverse outcomes Emotional effects of shortages Frustration, anger, mistrust Strain professional relationships

57 Adverse patient effects due to drug shortage

58 Tubing Misconnections

59 Forthcoming ISO standards for small bore connectors ISO General Requirements ISO Breathing Gas Systems ISO Enteral Feeding ISO Urological ISO Limb Cuffs ISO Neuraxial ISO Vascular/Luer fittings (formerly ISO 594)

60 This is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning.

Reducing the risk of serious medication errors in community pharmacy practice

Reducing the risk of serious medication errors in community pharmacy practice Reducing the risk of serious medication errors in community pharmacy practice Eastern Medicaid Pharmacy Administrators Association (EMPAA) November 1, 2017 Newport, Rhode Island Michael R. Cohen, RPh,

More information

Encouraging pharmacy involvement in pharmacovigilance; an international perspective.

Encouraging pharmacy involvement in pharmacovigilance; an international perspective. Encouraging pharmacy involvement in pharmacovigilance; an international perspective. Michael R. Cohen, RPh, MS, ScD (hon) DPS (hon) Chairperson, International Medication Safety Network and President, Institute

More information

Safe Medication Practices

Safe 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 information

Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center

Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center at the Maritime Institute Improving Staff Education

More information

BPOC/eMAR Spotlight on Performance Improvement

BPOC/eMAR Spotlight on Performance Improvement BPOC/eMAR Spotlight on Improvement Noel C. Hodges, R.Ph., MBA Division Director of Pharmacy Capital & Richmond Divisions Hospital Corporation of America HCA operates in 23 states and two foreign countries;

More information

Disclosure. Institute of Medicine (IOM) 1,2. Objectives 5/15/2014. Technician Education Day May 24, 2014 Ft. Lauderdale, FL

Disclosure. 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 information

student interests. The 1. Develop of error schema. develop

student interests. The 1. Develop of error schema. develop Sample Medication Safety APPE Student Rotation Rotation Description The medication safety rotation willl help students become familiar with the key principles utilized in hospitals and health systems to

More information

Objectives. Key Elements. ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management 5/20/2014

Objectives. Key Elements. ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management 5/20/2014 ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management Matthew Fricker, RPh, MS, FASHP Program Director, ISMP Rebecca Lamis, PharmD, FISMP Medication Safety Analyst,

More information

The Medication Safety Journey Natasha Nicol, Pharm. D., FASHP Director of Medication Safety June 4, 2009

The Medication Safety Journey Natasha Nicol, Pharm. D., FASHP Director of Medication Safety June 4, 2009 The Medication Safety Journey Natasha Nicol, Pharm. D., FASHP Director of Medication Safety June 4, 2009 About me I am someone s mother, wife, daughter, granddaughter, sister, aunt, cousin and niece. I

More information

Managing Pharmaceuticals to Reduce Medication Errors August 26, 2003

Managing Pharmaceuticals to Reduce Medication Errors August 26, 2003 Managing Pharmaceuticals to Reduce Medication Errors August 26, 2003 Susan M. Proulx, Pharm.D. President, Med-E.R.R.S. Subsidiary of ISMP (www.med-errs.com) Mission of ISMP Translate errors into education

More information

Medication Safety & Electrolyte Administration. Objectives. High Alert Medications. *Med Safety Electrolyte Administration

Medication 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 information

Medication Safety Way Beyond the 5 Rights

Medication 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 information

Human Factors. Frank Federico, RPh. This presenter has nothing to disclose.

Human Factors. Frank Federico, RPh. This presenter has nothing to disclose. Human Factors Frank Federico, RPh This presenter has nothing to disclose. 25 February 2015 Culture Learning System Improvement and Measurement Transparency Continuous Learning Accountability Teamwork &

More information

Medication 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 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 information

Preventing Medical Errors

Preventing Medical Errors Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.

More information

P2 Policies and Procedures for Institutions Working with PSOs

P2 Policies and Procedures for Institutions Working with PSOs Working With Patient Safety Organizations (PSOs) Ronni P. Solomon ECRI Institute P2 Policies and Procedures for Institutions Working with PSOs Ronni P. Solomon, Executive Vice President and General Counsel,

More information

How BPOC Reduces Bedside Medication Errors White Paper

How BPOC Reduces Bedside Medication Errors White Paper How BPOC Reduces Bedside Medication Errors White Paper July 2008 Brad Blackwell, M.S., R.Ph. Eloise Keeler, R.N., B.S.N. Abstract Medication errors are a significant source of harm to patients in U.S hospitals,

More information

WHAT are medication errors?

WHAT are medication errors? Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. webinars@thinkreliability.com www.thinkreliability.com Office 281-412-7766

More information

10/4/2012. Disclosure. Leading a Meaningful Event Investigation. Just Culture definition. Objectives. What we all have in common

10/4/2012. 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 information

Culture of Safety: What s in Your Toolbox?

Culture of Safety: What s in Your Toolbox? Culture of Safety: What s in Your Toolbox? Kathy Ghomeshi, PharmD, BCPS Medication Safety Specialist Victoria Serrano Adams, PharmD, FASHP, FCSHP Director of Pharmaceutical Services UCSF Medical Center

More information

Legislating Patient Safety: The California Experience. October 2003

Legislating Patient Safety: The California Experience. October 2003 Legislating Patient Safety: The California Experience October 2003 The Problem: Preventable medical errors are a huge and largely invisible cause of death in California and nationwide. In CA, an estimated

More information

Medication Safety in LTC. Objectives. About ISMP Canada

Medication 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 information

The Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS

The Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS The Importance of Transfusion Error Surveillance This is step #1 in error management Jeannie Callum, BA, MD, FRCPC, CTBS 6051 Clinical Errors 9083 Laboratory Errors 15134 Errors over 6 years I don t want

More information

Anatomy of a Fatal Medication Error

Anatomy 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 information

A shortage of everything except ERRORS

A shortage of everything except ERRORS Disclosure Succinylcholine Propofol Vitamin K Lorazepam Diltiazem Drug Shortages Current Status & State Survey Results Bill Stevenson Director of Pharmacy Oconee Medical Center I do not have a vested interest

More information

Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM

Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM Objectives Know TJC 2016 National Patient Safety Goals Discuss human factors on patient safety What is your role in patient safety?

More information

Patient Safety Incident Report Form

Patient Safety Incident Report Form Page 1 This form is not meant to be a substitute to the health region s incident reporting. The purpose of this form is to assist with the identification and management of adverse events and near misses;

More information

Just Culture Toolkit Scenarios

Just Culture Toolkit Scenarios Just Culture Toolkit Scenarios In order to promote a just culture where staff is comfortable in reporting errors or near misses, healthcare organizations must adopt a disciplinary system theory approach.

More information

Hallmarks of Patient Safety and Quality Improvement Programs in Pharmacy Practice

Hallmarks of Patient Safety and Quality Improvement Programs in Pharmacy Practice Hallmarks of Patient Safety and Quality Improvement Programs in Pharmacy Practice Jordan T. Daniel, PharmD Wednesday, May 10, 2017 Kimberly McDonough Spring Seminar Rhode Island Pharmacy Foundation Disclosure

More information

Medication Safety Technology The Good, the Bad and the Unintended Consequences

Medication Safety Technology The Good, the Bad and the Unintended Consequences Medication Safety Technology The Good, the Bad and the Unintended Consequences Michelle Mandrack RN, MSN Director of Consulting Services Matthew Fricker, RPh, MS Program Director 1 Objectives Consider

More information

Just and Accountable Culture (JAC): An Introduction

Just and Accountable Culture (JAC): An Introduction Just and Accountable Culture (JAC): An Introduction Maureen S Padilla, DNP, RN, NEA-BC Sr. VP and Chief Nurse Executive Co-Chair, Just & Accountable Steering Committee Yvonne Chu, MD, MBA Chief, Ophthalmology

More information

Required Organizational Practices Resources for 2016

Required Organizational Practices Resources for 2016 Required Organizational Practices Resources for 2016 ROPs Tests for Compliance Things to Consider Available Resources CLIENT IDENTIFICATION Working in partnership with clients and families, at least two

More information

NERC Improving Human Performance

NERC Improving Human Performance NERC Improving Human Performance Sentinel Event Reporting, Analysis and Prevention in Healthcare March 28, 2012 Charles A. Mowll, FACHE, CSSBB Executive Vice President The Joint Commission Healthcare Worker

More information

1. Medical Errors: The Scope of the Problem

1. Medical Errors: The Scope of the Problem 1. Medical Errors: The Scope of the Problem An Epidemic of Errors The November 1999 report of the Institute of Medicine (IOM), entitled To Err Is Human: Building A Safer Health System, focused a great

More information

Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA

Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA AnMed Health AnMed Health, located in Anderson, South Carolina, is one of the largest and most technologically advanced health systems

More information

JUST CULTURE FEBRUARY 20, 2013 KAREN ZANIN RN CNOR

JUST CULTURE FEBRUARY 20, 2013 KAREN ZANIN RN CNOR JUST CULTURE FEBRUARY 20, 2013 KAREN ZANIN RN CNOR Balance A Just Culture balances the need to learn from mistakes with the need to take corrective action against an individual if the individual s conduct

More information

Sharp 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 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 information

SHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE MEDICATION ERRORS

SHRI 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 information

Current Status: Active PolicyStat ID:

Current 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 information

THE INSTITUTE FOR SAFE MEDICATION PRACTICES: THE EXPERT WITNESS

THE INSTITUTE FOR SAFE MEDICATION PRACTICES: THE EXPERT WITNESS THE INSTITUTE FOR SAFE MEDICATION PRACTICES: THE EXPERT WITNESS Judy L. Smetzer, BSN, RN, FISMP jsmetzer@ismp.org 215-947-7797 2 Objectives Explain the mission and function of the Institute for Safe Medication

More information

Yoder-Wise: Leading and Managing in Nursing, 5th Edition

Yoder-Wise: Leading and Managing in Nursing, 5th Edition Yoder-Wise: Leading and Managing in Nursing, 5th Edition Chapter 02: Patient Safety Test Bank MULTIPLE CHOICE 1. In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital

More information

Introduction. Medication Errors. Objectives. Objectives. January What is a Medication Error? Define medication errors/variances

Introduction. Medication Errors. Objectives. Objectives. January What is a Medication Error? Define medication errors/variances Medication Errors Earlene Spence, Pharm.D., Miami VA Healthcare System Neena John, Pharm.D., Miami VA Healthcare System Eva Moreira, Pharm.D., Miami VA Healthcare System Chantal Chan, Pharm.D., Miami VA

More information

UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN

UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN 2014 1 PATIENT SAFETY PLAN 2014 PROGRAM GOALS The goal of the Patient Safety Program at University of Mississippi Medical Center (UMMC) is to

More information

End-to-end infusion safety. Safely manage infusions from order to administration

End-to-end infusion safety. Safely manage infusions from order to administration End-to-end infusion safety Safely manage infusions from order to administration New demands and concerns 56% 7% of medication errors are IV-related. 1 of high-risk IVs are compounded in error. 2 $3.5B

More information

Re-Engineering Medication Processes to Capitalize on Technology. Jane Englebright, PhD, RN Vice President, Quality HCA

Re-Engineering Medication Processes to Capitalize on Technology. Jane Englebright, PhD, RN Vice President, Quality HCA Re-Engineering Medication Processes to Capitalize on Technology Jane Englebright, PhD, RN Vice President, Quality HCA Who is HCA? % % % % U.K. % % % Switzerland % %% % % % % % %% % % % % % % % %% % % %

More information

Medication Error Reporting Systems: Problems and Solutions

Medication Error Reporting Systems: Problems and Solutions 1112-NM 1-2 November NEW 9/11/01 11:23 am Page 61 Medication Error Reporting Systems: Problems and Solutions David U, President and CEO, Institute for Safe Medication Practices, Ontario, Canada Reform

More information

Alaris System. Medication safety system focused at the point of care

Alaris System. Medication safety system focused at the point of care Alaris System Medication safety system focused at the point of care A safety platform you can build on TM Different care areas have different needs. That s why the Alaris System* gives you a platform you

More information

The Joint Commission Medication Management Update for 2010

The 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 information

Introduction. Singapore. Singapore and its Quality and Patient Safety Position 11/9/2012. National Healthcare Group, SIN

Introduction. Singapore. Singapore and its Quality and Patient Safety Position 11/9/2012. National Healthcare Group, SIN Introduction Singapore and its Quality and Patient Safety Position Singapore 1 Singapore 2004: Top 5 Key Risk Factors High Body Mass (11.1%; 45,000) Physical Inactivity (3.8%; 15,000) Cigarette Smoking

More information

N 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 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 information

High-Risk Medication Management Policy

High-Risk Medication Management Policy Department of Health and Human Services SYSTEM PURCHASING AND PERFORMANCE - MEDICATION STRATEGY AND REFORM High-Risk Medication Management Policy SDMS Id Number: Effective From: May 2014 Replaces Doc.

More information

INQUEST INTO THE DEATH OF: MARIE TANNER

INQUEST 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 information

The International Patient Safety Goals

The International Patient Safety Goals The International Patient Safety Goals Updated for 6 th edition Hospital Standards The International Patient Safety Goals What are The International Patient Safety Goals (IPSG)? Required as of 1 st January

More information

Financial Disclosure. Learning Objectives: Preventing and Responding to Sentinel Events in Surgery 10/13/2015

Financial Disclosure. Learning Objectives: Preventing and Responding to Sentinel Events in Surgery 10/13/2015 Preventing and Responding to Sentinel Events in Surgery Beverly Kirchner, BSN, RN, CNOR, CASC April 2014 Financial Disclosure I DO NOT have an actual, potential or perceived conflict of interest to disclose

More information

Just Culture. The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.

Just Culture. The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Just Culture November 2016 Just Culture The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Dr Lucian Leape Harvard School of Public

More information

Nursing Home Medication Error Quality Initiative

Nursing 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 information

A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES

A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University

More information

Practice Spotlight. Children's Hospital Central California Madera, California

Practice Spotlight. Children's Hospital Central California Madera, California Practice Spotlight Children's Hospital Central California Madera, California http://www.childrenscentralcal.org Richard I. Sakai, Pharm.D., FASHP, FCSHP Director of Pharmacy Services IN YOUR VIEW, HOW

More information

Sentinel Events and S Patient Patient entinel Event Alerts Safety Act Safety Ac Revised: BW/September 2010

Sentinel Events and S Patient Patient entinel Event Alerts Safety Act Safety Ac Revised: BW/September 2010 Sentinel Events Sentinel Events and Sentinel Event Alerts Revised: BW/September 2010 Patient Patient Safety Safety Act Act What is a Sentinel Event? 0 A sentinel event is an unexpected occurrence involving

More information

WPSC Teleconference Avoiding Never Events. Linda Furkay, PhD, RN Patient Safety Adverse Event Officer

WPSC Teleconference Avoiding Never Events. Linda Furkay, PhD, RN Patient Safety Adverse Event Officer Linda Furkay, PhD, RN Patient Safety Adverse Event Officer Share Findings from adverse events surgical errors, pressure ulcers, & falls Successful patient safety strategies here in Washington & from other

More information

POLICY/PROCEDURE PLAN GUIDELINE. SECTION: I Administrative

POLICY/PROCEDURE PLAN GUIDELINE. SECTION: I Administrative TITLE: Patient Safety Occurrence Report POLICY PTCADM100.23 SCOPE: Children's Hospital of Pittsburgh ("CHP") Main Children's Hospital of Pittsburgh Satellites Children's Hospital of Pittsburgh Ambulatory

More information

Improving Safety Practices Anticoagulation Therapy

Improving Safety Practices Anticoagulation Therapy Improving Safety Practices Anticoagulation Therapy Katie Cinnamon, PharmD, BCPS Clinical Pharmacist Genesis Medical Center - Davenport Objectives Review background information on medication errors and

More information

Supplementary Appendix

Supplementary 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 information

National Patient Safety Goals from The Joint Commission

National Patient Safety Goals from The Joint Commission National Patient Safety Goals from The Joint Commission Objectives After completion of this module, participants will be able to: List at least five National Patient Safety Goals that are required in a

More information

Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10

Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10 Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10 Policy : 5.24 Subject: Supersedes: Effective: October 8, 2008 Revised: July 1, 2002, December 1, 2012 Reviewed: December 1, 2012 Response

More information

Adverse 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 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 information

Objectives. Demographics: Type and Services 1/22/2014. ICAHN Aggregate Results. ISMP Medication Safety Self Assessment for Hospitals

Objectives. Demographics: Type and Services 1/22/2014. ICAHN Aggregate Results. ISMP Medication Safety Self Assessment for Hospitals ICAHN Aggregate Results ISMP Medication Safety Self Assessment for Hospitals Matthew Fricker, RPH, MS, FASHP Rebecca Lamis, PharmD, FISMP January 23, 2014 1 Objectives Report the demographic characteristics

More information

#104 - Prevention of Medical Errors [1]

#104 - Prevention of Medical Errors [1] Published on Excellence In Learning (https://excellenceinlearning.net) Home > #104 - Prevention of Medical Errors #104 - Prevention of Medical Errors [1] Please login [2] or register [3] to take this course.

More information

One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration

One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration Presented by: Marla Husch Northwestern Memorial Hospital Northwestern Memorial Hospital Chicago, Illinois

More information

10/9/2011. At the end of this program, the learner will be able to:

10/9/2011. At the end of this program, the learner will be able to: Medical Errors Prevention Gail Fox-Seaman, MSN, ARNP VA Medical Center West Palm Beach, Fl. At the end of this program, the learner will be able to: Define root cause analysis (RCA), List the five most

More information

Care of the Caregiver STARTS and ENDS with full leadership support and involvement!

Care of the Caregiver STARTS and ENDS with full leadership support and involvement! Care of the Caregiver STARTS and ENDS with full leadership support and involvement! Care of the caregiver following an unintentional error or near miss should ideally incorporate: Unsafe Acts Algorithm

More information

To prevent harm to patients from adverse medication events involving high-alert medications.

To 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 information

Introduction. Singapore and its Quality and Patient Safety Position. Singapore 2004: Top 5 Key Risk Factors. High Body Mass

Introduction. Singapore and its Quality and Patient Safety Position. Singapore 2004: Top 5 Key Risk Factors. High Body Mass Introduction Singapore and its Quality and Patient Safety Position Singapore 2004: Top 5 Key Risk Factors High Body Mass (11.1%; 45,000) Physical Inactivity (3.8%; 15,000) Cigarette Smoking (7.4%; 28,000)

More information

Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1.

Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1. Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall Application Analysis Total 1. CULTURE 2 12 4 18 A. Assessment of Patient Safety Culture 1. Identify work settings

More information

PATIENT SAFETY KNOWLEDGEBASE. How to prepare for a Survey

PATIENT SAFETY KNOWLEDGEBASE. How to prepare for a Survey PATIENT SAFETY KNOWLEDGEBASE How to prepare for a Survey 1 DEFINITIONS Patient Safety v is a process that guards against any adverse condition occurring in a patient as a result of wrong diagnosis or treatment

More information

Preventing Medical Errors Presented by Debra Chasanoff, MEd, OTR/L FOTA Annual Conference - November 9, 2013

Preventing Medical Errors Presented by Debra Chasanoff, MEd, OTR/L FOTA Annual Conference - November 9, 2013 Preventing Medical Errors Presented by Debra Chasanoff, MEd, OTR/L FOTA Annual Conference - November 9, 2013 This program was designed to meet the criteria in section 456.013(7), Florida Statutes, which

More information

Improving the Safety of International Non-proprietary Names of Medicines (INNs) Position Statement 2011

Improving the Safety of International Non-proprietary Names of Medicines (INNs) Position Statement 2011 Improving the Safety of International Non-proprietary Names of Medicines (INNs) Position Statement 2011 The International Patient Safety Network The International Medication Safety Network (IMSN) is an

More information

The Joint Commission Medication Management Update for 2010

The Joint Commission Medication Management Update for 2010 The Joint Commission Medication Management Update for 2010 U.S. Army Manager, Army Patient Safety Program U.S. Army Medical Command Fort Sam Houston, TX CPE Information and Professional Resources & Business

More information

STATEMENT. JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration

STATEMENT. JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration STATEMENT JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration Institute of Medicine Committee on Patient Safety and Health Information Technology

More information

3/9/2010. Objectives. Pharmacist Role in Medication Safety and Regulatory Compliance

3/9/2010. 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 information

High Alert Medications: Reducing Patient Harm

High Alert Medications: Reducing Patient Harm High Alert Medications: Reducing Patient Harm Building a Bridge to Better Health Coalition Brian D. Esters, PharmD, CPPS Assistant Professor of Pharmacy Practice Tennessee Pharmacist Coalition Vision Reduce

More information

IMPACT OF TECHNOLOGY ON MEDICATION SAFETY

IMPACT OF TECHNOLOGY ON MEDICATION SAFETY Continuous Quality Improvement IMPACT OF Steven R. Abel, PharmD, FASHP TECHNOLOGY ON Nital Patel, PharmD. MBA MEDICATION SAFETY Sheri Helms, PharmD Candidate Brian Heckman, PharmD Candidate Ismaila D Badjie

More information

Update on Pharmacy Issues in Long Term Care Lisa Nichols RPh, CGP

Update on Pharmacy Issues in Long Term Care Lisa Nichols RPh, CGP Update on Pharmacy Issues in Long Term Care Lisa Nichols RPh, CGP 1.Review What a Consultant Pharmacist Does and the Role of Pharmacy for Long Term Care Facilities 2.Identify Key Components of a Medication

More information

How Should Policy Reflect a Culture of Safety?

How Should Policy Reflect a Culture of Safety? How Should Policy Reflect a Culture of Safety? BETA Healthcare Group BETA HEART Domain I: Culture of Safety All Rights Reserved 2016 Table of Contents How Should Policy Reflect a Culture of Safety?...

More information

Guidance for Medication Reconciliation and System Integration Process

Guidance for Medication Reconciliation and System Integration Process Guidance for Medication Reconciliation and System Integration Process Identifying points of failure within the medication reconciliation process and determining systematic approaches (via health IT) to

More information

Consumers Union/Safe Patient Project Page 1 of 7

Consumers Union/Safe Patient Project Page 1 of 7 Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several

More information

What Every Patient Safety Officer Must Know:

What Every Patient Safety Officer Must Know: What Every Patient Safety Officer Must Know: Tapping into the Best Resources in the Country John R. Combes, MD Senior Medical Advisor Hospital and Healthsystem Association of Pennsylvania Harrisburg, PA

More information

Assessing and improving the use of near-miss reporting to prevent adverse events and errors in rural hospitals

Assessing and improving the use of near-miss reporting to prevent adverse events and errors in rural hospitals Assessing and improving the use of near-miss reporting to prevent adverse events and errors in rural hospitals John M. Kessler, B.S. Pharm., Pharm. D. Steve C. Dedrick, MS Pharm. NCCMedS Project Directors

More information

PROCESS FOR HANDLING ELASTOMERIC PAIN RELIEF BALLS (ON-Q PAINBUSTER AND OTHERS)

PROCESS FOR HANDLING ELASTOMERIC PAIN RELIEF BALLS (ON-Q PAINBUSTER AND OTHERS) PROCESS FOR HANDLING ELASTOMERIC PAIN RELIEF BALLS (ON-Q PAINBUSTER AND OTHERS) REQUIRES SAFETY IMPROVEMENTS From the July 16, 2009 issue Problem: In our May 21, 2009, newsletter we noted an association

More information

Prevention of Medical Errors

Prevention of Medical Errors Prevention of Medical Errors LEARNING OBJECTIVES Introduction: Define medical error, adverse event, side effects, close calls or near miss, never event, and sentinel event. Identify the classifications

More information

Serious Reportable Events in Healthcare 2011 Update

Serious Reportable Events in Healthcare 2011 Update Serious Reportable Events in Healthcare 2011 Update July 19, 2011 1 Overview Purpose 2002, 2006, 2011 Facilitate uniform, comparable public reporting Enable systematic learning Ensure currency & appropriateness

More information

PHARMACY SERVICES/MEDICATION USE

PHARMACY SERVICES/MEDICATION USE 25.01. 10 Drug Reactions & Administration Errors & Incompatibilities. Drug administration errors, adverse drug reactions and incompatibilities must be immediately reported to the attending physician and

More information

PATIENT SAFETY OVERVIEW

PATIENT SAFETY OVERVIEW PATIENT SAFETY OVERVIEW MUHAMMAD ISLAM, MBBS, MS, MCH, LSSBB DIRECTOR OF PATIENT SAFETY SUNY DOWNSTATE MEDICAL CENTER 1 DEFINITIONS Patient Safety v is a process that guards against any adverse condition

More information

Preventing Medical Errors Presented by Debra Chasanoff, MEd, OTR/L FOTA Annual Conference November 3, 2017

Preventing Medical Errors Presented by Debra Chasanoff, MEd, OTR/L FOTA Annual Conference November 3, 2017 Preventing Medical Errors Presented by Debra Chasanoff, MEd, OTR/L FOTA Annual Conference November 3, 2017 This program was designed to meet the criteria in section 456.013(7), Florida Statutes, which

More information

Considerations for Sterile Compounding of Parenteral Products for Pediatric Use: Part 2 PharMEDium Lunch and Learn Series LUNCH AND LEARN

Considerations for Sterile Compounding of Parenteral Products for Pediatric Use: Part 2 PharMEDium Lunch and Learn Series LUNCH AND LEARN LUNCH AND LEARN Considerations for Sterile Compounding of Parenteral Products for Pediatric Use: Part 2 November 10, 2017 Featured Speaker: Kirsten H. Ohler, PharmD, BCPS, BCPPS Neonatal / Pediatric Clinical

More information

Overview. Diane Cousins, R.Ph U.S. Pharmacopeia. 1 Pharmacy Labeling with Color

Overview. 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 information

Pharmacovigilance & Managed Care Pharmacy. Issues for Medication Safety in Korea

Pharmacovigilance & Managed Care Pharmacy. Issues for Medication Safety in Korea Pharmacovigilance and Managed Care Pharmacy Issues for Medication Safety in Korea Hyun Taek Shin, Pharm.D. Professor, College of Pharmacy Sookmyung University & President, Korean Academy of Managed Care

More information

MEDICATION 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 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 information

According to Lucian Leape, Professor of Health Policy at

According to Lucian Leape, Professor of Health Policy at A Statewide Approach to a Just Culture for Patient Safety: The Missouri Story Rebecca Miller, MHA, CPHQ, FACHE; Scott Griffith, MS; and Amy Vogelsmeier, PhD, RN The Missouri Just Culture Collaborative

More information

Most of you flew to this meeting

Most of you flew to this meeting Most of you flew to this meeting on an airplane and, like me, ignored the flight attendant asking you to pay attention and listen to a few safety warnings that were being offered. In spite of having listened,

More information