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Medication errors and how to prevent them

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Hello, everyone. Welcome to the presentation. I am Lee, Pei-Chen, the clinical pharmacist at Taipei Veterans General Hospital in Taiwan. The topic of my presentation is “medication safety and drug shortages management”. In the first part of the section, I will illustrate the definition of medication safety in hospitals. In order to improve medication safety, the key step is to reduce drug-related problems, such as medication errors and adverse drug events or reactions. After listening to the section, you should realize the importance of medication safety for patients in hospitals and know how to cope with drug-related problems, including identification, reporting and prevention of medication errors and adverse drug events or reactions by system approaches and clinical pharmacist interventions.
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Let’s start with part one, medication safety in hospitals. In the guidelines on Good Pharmacy Practice, pharmacists should provide effective medication therapy management through the process of medication utilization. Here are the definitions of drug-related problems, medication errors, adverse drug reactions and adverse drug events. Adverse drug reaction Means Any response to a drug which is noxious and unintended and which occurs at doses normally used in humans for prophylaxis, diagnosis or therapy of disease Generally speaking, Drug-related problems include all issues that can potentially affect the success of pharmacotherapy in a given patient. Previous studies have shown that medication errors may happen in each medication use process.
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When we look into the sources of medication errors, the physician prescribing and patient administration errors have been reported as 6.5 %, First, let’s take a glance at the types of medication errors. When the prescriptions are transcribed, some errors also occur between different medical professionals. That may result from Preparation and dispensing errors include Calculation error, Preparation error, or correct prescription but dispense to wrong patient or wrong drug. Administration error may be cause by nurse or patients themselves, Adverse drug reaction can be divided into two types. One is Predictable ADR, that is so-called type A reaction. Type A reaction has higher Incidence rate, lower mortality rate. It is related to Dose and pharmacological effects.
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For example, patient who takes benzodiazepine may feel sedative, drowsiness. Another is Unpredictable ADR that is so-called type B reaction. Type B reaction has lower Incidence rate, higher mortality rate. It is NOT related to Dose or pharmacological effects. At Taipei Veterans General Hospital Medicines, storage and shelf life management are achieved by bar code system. To ensure drug delivery safety, we utilize whole new medicine trolleys equipped with doors and locks. Each ward is given a unique key for delivery box. 40 error-proofing mechanisms in CPOE Query systems include Formulary, Package inserts, Drug images, Drug classification, Clinical uses ,Shortage drugs ubstitution, Reimbursed regulations. Checking systems include Duplication, Dosage, Inappropriate dosage form Interaction, Pregnancy, Contraindication, Renal functions, Allergy and ADR.
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We also establish the pharmacist verifying system”. Pharmacists perform verifications right after physician prescribing based on multiple database. In our pharmacy, the un-prevented dispensing error is controlled to less than six sigma, which is three point four ppm, We are the first hospital to use barcode medication administration system in Taiwan. When the nurse is on service, the administration cart is carried to bedside. Our clinical pharmacists join ward rounds, physician outpatient clinics; provide medication consultation, patient education. Online medication error and ADR reporting systems are established to maintain our quality and medication safety. All of the medical professionals can report ME or ADR via the system.

For the last 2 weeks, we covered how medication use is managed. However, medical errors are bound to occur, thus it is important in knowing what kind of medical errors there are and how to prevent/deal with them. Like medical errors, drug shortages may arise despite good inventory management.

In this step, Lee will address the various medical errors, and how they are managed at TVGH.

Key points

According to the Good Pharmacy Practice (GPP), pharmacists should provide effective medication therapy management (MTM).

Drug-related problems include:

  • Medication errors

  • Adverse drug reactions

  • Adverse drug events

  • Broadly speaking, drug-related problems include all issues that potentially affect the success of medication treatment.

Medication errors:

  • Prescription errors

  • Transcription errors

  • Preparation and dispensing errors

  • Administration errors

Adverse drug reactions (ADR) can be divided into two types.

  • Type A: predictable ADR. Higher incidence rate, lower mortality rate. It is related to dose and pharmacological effects.

  • Type B: unpredictable ADR. Lower incidence rate, higher mortality rate. Not related to dose or pharmacological effects.

At TVGH:

Various strategies are put in place to prevent errors. These include utilizing the bar code system, and medicine trolleys equipped with doors and locks, 40 error-proofing mechanisms in CPOE query and checking systems. Pharmacists also verify right after physician prescribing based on multiple databases. There is also an online medication error and ADR reporting system to maintain service quality and medication safety. All medical professionals can report ME or ADR via the system.

Share and learn:

How do you respond to ADRs in your hospital?

What are the preventative strategies utilized in your hospital?

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Good Pharmacy Practice: Medication Management

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