Medication Errors

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????????????????????????? ?????????

• ???????
• 1. ??????????????????????????
• 2. ??????????????????????????????
• 3. ???????????????????????
• 4. ?????? ??????????????????????????????????
• ????????????????????
• ???????????????????? ?????????????????

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Medication Errors
Jitra Anuras, M.D. Bumrungrad International
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Medication Use Process

• Prescribing / Ordering
• Transcribing
• Dispensing
• Administering
• Monitoring

Effective Communication
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Swiss Cheese Model of Medication Error Prevention
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Prescribing Errors
?????????????????

1. ???????????????????????????? prescription
2. ?????????????????????????????????????????
3. ????????????????????????????????????
4. ??????????????????????????????????
5. ?????????????????????????? Human Factors
6. ???????????????????????????????
7. ??????????????????????? (Mis-identification of
   patient)

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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
1. ?????? ?????????????????????
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Prescribing Errors
????????????????
I. ???????????????????????????????????????
prescription
1.1 ??????????????????????????? 1.2 ?????????
block letter 1.3 ??????? computerized physician
order entry (CPOE) 1.4 ????????????
??????????????????????????????????????
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
2. ???????? prescription ?????????????
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Prescribing Errors
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2. ??????????????????? prescription ?????????? "5
Rights"
Right patient Right drug Right dose Right
route Right time
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Prescribing Errors
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I. ???????????????????????????? prescription
3. ?????????????? ?????????? ????????????
????????????????????
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Prescribing Errors
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3. ???????????????
3.1 ??????????????????? 3.2 ???????????
???????????????????? (Dangerous
Abbreviations) 3.3 ???????? List
????????????????????????????????? eg. MSO4,
MgSO4 3.4 ??? " Tall Man Lettering"
??????????????????????? ???? NasaCORT,
NasoNEX ("Tall Man Lettering" is when part
of the drug name is written in upper case
letters to help distinguish one drug from
another) 3.5 ?????????????????????????????????????
???????????????
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
4. ???? ??????????? ????????????????????????
????????????? 4 ?. ????????? 0
??????????????? (Leading zero) ???? .5 mg 4
?. ?????? 0 ???????????????? (Trailing zero)
???? 5.0 mg 4 ?. ????????????????(Dangerous
Abbreviations) ???????????? ???? U,
IU, µg, cc, ?.?., ?.?., ?.?., Gr. 4 ?.
???????? / ??????????????????????
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Prescribing Errors
????????????????
4.1 ???????? ???? ??????????? (strength or
concentration) ?????? ????? metric ???? 20mg 4.2
??????????????????????????? wt/vol ???? 50
mg/mL 4.3 ????????? 0 ??????????????? ?????????
??? 0 ???????????????? 4.4 ?? List ?????????????
(Dangerous Abbreviations)?????????? U, IU
?????? unit ??? µg ??????
mcg ??? cc, ?.?. ?????? mL
??? ?.?., ?.? ?????? 5 mL ??? 15 mL
??????? 4.5 ???????????????? (apothecary system)
???? grain, dram ( ) ???? minim (
) 4.6 ????????????? ???????????????????????????? 4
.7 ?????? computer ?????????????????????????????
???? under ???? over dosage
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List of Dangerous Abbreviations
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Cont
List of Dangerous Abbreviations
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
5. ??????? preparation ????????????????????????
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Prescribing Errors
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5. ???? preparation ???? otic drop,
ophthalmic ointment
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
6. ?????????????????????????
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Prescribing Errors
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6.1 ???????????????????? metric ???? 100
tablets 6.2 ???????????????? ??????? package
????????? ???? ??? ???????
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
7. ???????????? (direction of use) ???????????
- dose, route, frequency -
??????????????? (Dangerous Abbreviation)
???? O.D, QD, QID, QOD, ???
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Prescribing Errors
????????????????
7.1 ???????? ???? ??????????????????? Arabic
??????????? metric ???? 1 mg, 15 mg, 15
mL 7.2 ???? route ???? P.O., IM, IV 7.3
??????????????? ???? M 7.4 ???????? frequency
???? ??????????, ????????? ????????? 7.5
?????????????????? (Dangerous Abbreviations)
??? once daily ???? ????? 1 ???????? OD, QD
???????? 4 ????? ??? QID ?????????????
??? QOD ???? ???
V
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Prescribing Errors
????????????????
7.6 ???????????????????? 7.7 ????????????? ????
" Take as directed 7.8 ????????????????? 24
??., 48 ??., 72 ??.??????????????????
??????? ????? ?????? ?????? 7.9 ??????? CPOE
(computerized physician order entry) ,
computerized calculation of weight-based
dosage 7.10 ??? pre-printed orders
??????????????? ???? chemotherapeutic drugs
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
8. ???????????????????????????? "??????", "RM",
???? Continue home medications
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Prescribing Errors
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8.1 ??????????????????????????? RM, ??????,
???? " continue home medications"
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
9. ???? "hold" order ?????????????????????
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Prescribing Errors
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9.1 ??????? "hold" order ?????????????????????????
????????? 9.2 ??????????? medication
reconciliation (Medication Reconciliation
is a process for comparing the patients
current medications with those ordered for the
patient while under the care of the
organization)
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Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
10. ????????????????????? ????????????????????????
?? ????????????????????????????????????????
?
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Prescribing Errors
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10.1 ?????????????????????????????????????????
???????????????????? ???? beeper
??????????? ????????? 10.2
?????????????????????????????????????????
??????????????????????
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Prescribing Errors
?????????????????
II. ?????????????????????????????????????????
1. ?????????????????? 2. ????????????????????
physician's order sheet ????? 3.
????????????????? ???????????????????????????????
4. ????????????????????????????????????????
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Prescribing Errors
????????????????
1. ????????????? ??????????????????????????????? 2
. ???????????????????????????? ???????????????? 3.
????????????????????????????????????????????? 4.
??????????????? ???? BI.D., T.I.D.?????? ????? 2
????? ???? ????? 3 ???????? 5. ???????????????????
???????order sheet ????? ????????????? (Read
back) ?????????? confirm ?????????? 6.
????????????????????????????????????????????
(cosign) ????? 24 ??????? ?????? ?.?.
????????????????????????????????????
????????sticker 7. ???????? List ?????????????
??????????????????? ???? ??????????? ????
Chemotherapeutic agents
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Prescribing Errors
?????????????????
III ????????????????????????????????????
1. ??????????????????????????? 2.
?????????????????????????? 3. ???????????? drug
interaction ??????????????? 4.
????????????????????????????? ????
??????????????? ????????? DVT ????
preoperative prophylactic antibiotics
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Prescribing Errors
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III ?????????????????????????????????
1. ?? List of current medications ??????????
???????????????????????? ???????????????
????????? ????????????? 2. ??????????? Medication
Reconciliation ????????????????????
???????????, ??????? care settings,
???????????????? ??????? (Medication
Reconciliation is a process for comparing the
patients current medications with those
ordered for the patient while under the
care of the organization) 3. ????????????????????
???????????????? ?????????????? 4. ?????????????
drug interaction ?????????? IT ?????????????????
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Prescribing Errors
?????????????????
III ????????????????????????????????????
5. ?????????????? contraindication
???????????????????? ???? ?? sulfa ?????????
G6PD ???? beta-blocker ??????????????? 6.
???????????????????????????? ??????????? cross
reaction ???????????????????? 7.
???????????????????????????????????? ?????????
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Prescribing Errors
????????????????
III ?????????????????????????????????
5. ?? List of current medical problems ????
diagnosis 6. ????????? " Drug Allergy"
??????????????????????????, OPD clinical
record, ???? order sheet ???????? update
????????????????????????????????
??????????????????? 7. - ????????????????????????
????????????????????? ???? ????? -
??????????? (IT) ?????????????????????? ????
????? 8. - ??????????????????????????????????????
???????????????????????? ???????
????????????????????????????????????????? ????
??????? care settings (Hand-off
communication) - ????????????????????????????
??????????? Hand-off communication
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Prescribing Errors
?????????????????
IV ??????????????????????????????????
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Prescribing Errors
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IV ????????????????????????????????????????
patient care team ???????????????
1. ????????????????????????? (Formulary)
????????????????????????????, preparation,
dosage, ???????, adverse effects, drug
interaction 2. ?????????? ?????? IT System 3.
??????????????????????????????????????????????????
??? 4. ????? update ???????????????????????? 5.
?? List ??? Look-alike, Sound-alike (LASA) drugs
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Prescribing Errors
????????????????
IV ????????????????????????????????????????
patient care team ???????????????
6. ?? List ??? High-alert drugs 7.
?????????????????????????????????????????????????
8. ?? Protocol ???? order sets
????????????????????? ???? anticoagulants,
chemotherapeutic drugs ???????
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Prescribing Errors
?????????????????
V ?????????????????????????? Human Factors
1. ??????????????????? ???????????????????????????
?????? 2. ?????????????????????????????????? 3.
???????????????????????????? prescription ????
???????????????????? ???????????????????????
??????? 4. ??????????????????????????????? ????
?????? ????????????????????????
????????????????? ???? ??????????????????
(Disruptive Behaviors) ?????????? 5. ????? dose
???????????????????????????????????????
?????????????? ???? ?????????????
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Prescribing Errors
????????????????
V ???????????????????????????? Human Factors
1. ?????????????? ????????????????? ????
????????????????????????? 2. ?????????????????????
????????????????????????? 3. ?????????????????????
??????????????????? ???? ????????????
??????????? 4. ???????? policy ???????????????????
??????????????????? ??????????? ????????????
disruptive behaviors ????????????? (Code of
conducts) 5. - ???????????? dose ?????????
weight-based ???????? - ?????? computer
?????????????? - ????????????? confirm
???????? dose ??
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Prescribing Errors
?????????????????
VI ???????????????????????????????
- ?????????????????? - ???????????????
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Prescribing Errors
????????????????
VI ?????????????????????????????????????
- ????????????????? - ???????????????
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Prescribing Errors
?????????????????
VII ??????????????????????? (Mis-identification
of patient)
- ??????? - ??????????????????????
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Prescribing Errors
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VII ????????????????????????????????????????
(Correct identification of patient)
1. ??? 2 ????????? (2 identifiers) ????????
??????? ????????????????????? Hospital
Number 2. ?????????????????? ????
?????????????????? 3. ????????????????????????????
????????????????????? ??????? coma ????????? 4.
?????? ???/ ???? bar code ?????? 5. ????? 2
??????????????????????????????????????????????????
?????????????? ????????
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Monitoring Errors
?????????????????
1. ??????????????????????????????????????
??????????? ?????????????????????????????????????
???? ?????????? Opioid ???? Sedative
?????????? Monitor respiratory rate ???? O2
Sat
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Monitoring Errors
?????????????
1. ????? Monitor ????? ??? follow up
????????????????? ?????????????????????
???????????????????????????
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Monitoring Errors
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2. ??????????????????????????? ???????????????
???????????????????? ????????? ????????
???? ??????? BUN, creatinine ????????
nephrotoxic drugs, ??????? Liver function tests
??????????????? statin ???????????blood level
????? ???????
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Monitoring Errors
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2. ?? Protocol ?????? laboratory monitoring
blood levels, kidney function ???? liver function
??? lab tests ????? ?????????????
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Monitoring Errors
?????????????????
3. Technique ?????????????????????? ????
??????? existing IV Line ??????? lab
???????????
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Monitoring Errors
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3. ???????????????????????????????? ????
body fluid ????? ??????? laboratory tests
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Monitoring Errors
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4. ????????????????? ??? ??????????????????
critical lab results ??????????????
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Monitoring Errors
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4. ?? protocol ?????????????????? report critical
lab results ????????????????????????????
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Monitoring Errors
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5. ??????????? review ?? Labs ?????????????????
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Monitoring Errors
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5. ???????????????? labs ?????????????? ???
review lab results ???? ??? ?????????
??????????
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Monitoring Errors
?????????????????
6. ????? protocol ???????? ??? monitor
?????????????????????
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Monitoring Errors
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6. ?? protocol ??????????????? ??? monitor
????????????????????? 6.1 ??????? sedatives
????????????? conscious, moderate, ???
deep sedation 6.2 insulins 6.3 narcotics
6.4 anticoagulants
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Monitoring Errors
?????????????????
7. ?????????????? monitor medication errors
incidents
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Monitoring Errors
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7. ?????????????????????? medication error
incidents ??????? incident reports, root
cause analysis ??? corrective actions
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• The End
• Thank You