John F. Mitchell, Pharm.D., FASHPMedication Safety ConsultantRecipient, ISMP CHEERS AwardformerlyMedication Safety CoordinatorUniversity of Michigan HospitalsUh oh, did “I” do that ? Medication Errors in Long-Term Care
•Define medication errors and classify their significance•Understand the extent of medication errors and their impact on patient care•Discuss the many factors that contribute to errors and the impulse to “place blame” on healthcare workers•Examine approaches to minimize the risk of medication errors with applications to LTCOur goals for today
To Err Is HumanKohn LT, Corrigan JM, Donaldson MS, Eds. To Err Is Human. Washington National Press, Wash, DC. 2000.
"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to:Defining medication errorsNational Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at ; Jan. 2012.•professional practice•health care products•procedures and systems•product labeling, packaging, and nomenclature•dispensing•distribution•administration•education•monitoring
If you saw this, would you fly ?Extra ExtraAirlines expect 1-2jets to crash dailyOver 1000 deaths expected weekly
Buy what about being a patient in the health care systemKohn et al. Committee on quality health care in America. IOM. Academy Press. 1999.Extra ExtraAirlines expect 1-2 jets to crash dailyOver 1000 deaths expected weekly=44,000 – 98,000deaths annuallydue tomedical errors
Accidents123,706MedicalErrors~100,000Alzheimer's74,632Diabetes71,382. Accessed Jan 2012. Based on 2007 data.How medical errors rank as cause of mortalityHeart616,067 Cancer562,875 Stroke135,952 Lung127,924
Some reasons errors occur•poor communications within healthcare team•verbal orders•poor handwriting•improper drug selection•missing medication•incorrect scheduling•look alike / sound alike drugs•polypharmacy•availability of floor stock (no second check)•drug interactions•hectic work environment•lack of computer decision support
NCC MERP. accessed Jan 2012. Classifying medication errorsA circumstances exist for potential errors to occurB an error occurred but did not reach the patientC error reached the patient but did not cause harmD patient monitoring required to determine lack of harmE
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