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INTRODUCTION

KEY CONCEPTS

  • Image not available. Medication errors (MEs) are defined as any mistake at any stage of the medication-use process; adverse drug events (ADEs) are the result of an injury as a result of an ME.

  • Image not available. All MEs can be prevented, while ADEs can be categorized as preventable and potential.

  • Image not available. MEs occur at an alarmingly high rate, with some ADEs having fatal outcomes for patients.

  • Image not available. MEs can occur at any step of the medication-use process: selection and procurement, storage, ordering and transcribing, preparing and dispensing, administration, or monitoring.

  • Image not available. Determining the actual and potential root causes of MEs helps to correct future errors in the medication-use system.

  • Image not available. Quality improvement methods that prevent MEs and thereby minimize ADEs include identifying the ME and/or ADE, understanding the reasons for the ME and/or ADE, designing and implementing changes to prevent an ADE or ME, and checking the outcome of that change.

  • Image not available. Healthcare organizations have implemented various measures to reduce the incidence of MEs and ADEs, such as computerized physician order entry (CPOE), automated drug distribution systems, bar-code scanning, and “smart” infusion pumps with decision support and where information is passed in a bidirectional manner between the pump and the patient’s electronic medical record (EMR).

  • Image not available. Medication reconciliation or comparing a patient’s current medication orders to all of the medications that the patient had been taking before any care transition (hospital admission, transfer, or discharge) is a vital process in preventing MEs and ADEs.

  • Image not available. Promoting a “Just Culture” of medication safety cultivates trust in the workplace that makes personnel feel comfortable sharing safety information (eg, unsafe situations) and assuming personal responsibility and accountability for complying with safe medication practices.

PRECLASS LEARNING ACTIVITY

Watch the http://www.youtube.com/watch?v=P2a69klu37k video entitled “CUSP: Understand Just Culture,” sponsored by the Agency for Healthcare Research and Quality. This 5.5-minute video describes the fundamental tenets of a Just Culture environment with examples that clarify the concept. Use the video to think about a patient care situation where a medication error occurred—and how it was managed and resolved. Write down two to four ways the Just Culture Concepts were used—or not used—in that situation.

Medical errors are not a new phenomenon. Medical errors causing harm may lead to devastating effects on patients. In 1991, the Harvard Medical Practice Study showed that a significant number of people are victims of medical errors, and a subset experienced medication errors (MEs). This landmark study reviewed the incidence of adverse events and negligence in hospitalized patients in the state of New York showing that almost 4% of patients experienced an iatrogenic injury (one caused by healthcare practices or procedures), prolonging their hospital stays.1 Importantly, nearly 14% of those mistakes were fatal. Examples of mistakes noted in the Harvard study included renal failure from angiographic dye and a missed diagnosis of colon cancer. Drug complications were the most common type of outcome attributed to negligence, accounting for 19% of these preventable adverse events.1

The ...

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