Title: Medication Errors
1????????????????????????? ?????????
- ???????
- 1. ??????????????????????????
- 2. ??????????????????????????????
- 3. ???????????????????????
- 4. ?????? ??????????????????????????????????
- ????????????????????
- ???????????????????? ?????????????????
2Medication Errors
Jitra Anuras, M.D. Bumrungrad International
3Medication Use Process
- Prescribing / Ordering
- Transcribing
- Dispensing
- Administering
- Monitoring
Effective Communication
4Swiss Cheese Model of Medication Error Prevention
5Prescribing Errors
?????????????????
- ???????????????????????????? prescription
- ?????????????????????????????????????????
- ????????????????????????????????????
- ??????????????????????????????????
- ?????????????????????????? Human Factors
- ???????????????????????????????
- ??????????????????????? (Mis-identification of
patient)
6Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
1. ?????? ?????????????????????
7Prescribing Errors
????????????????
I. ???????????????????????????????????????
prescription
1.1 ??????????????????????????? 1.2 ?????????
block letter 1.3 ??????? computerized physician
order entry (CPOE) 1.4 ????????????
??????????????????????????????????????
8Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
2. ???????? prescription ?????????????
9Prescribing Errors
????????????????
2. ??????????????????? prescription ?????????? "5
Rights"
Right patient Right drug Right dose Right
route Right time
10Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
3. ?????????????? ?????????? ????????????
????????????????????
11Prescribing Errors
????????????????
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 ?????????????????????????????????????
???????????????
12Prescribing 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 ?.
???????? / ??????????????????????
13Prescribing 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
14List of Dangerous Abbreviations
15Cont
List of Dangerous Abbreviations
16Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
5. ??????? preparation ????????????????????????
17Prescribing Errors
????????????????
5. ???? preparation ???? otic drop,
ophthalmic ointment
18Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
6. ?????????????????????????
19Prescribing Errors
????????????????
6.1 ???????????????????? metric ???? 100
tablets 6.2 ???????????????? ??????? package
????????? ???? ??? ???????
20Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
7. ???????????? (direction of use) ???????????
- dose, route, frequency -
??????????????? (Dangerous Abbreviation)
???? O.D, QD, QID, QOD, ???
21Prescribing 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
22Prescribing 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
23Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
8. ???????????????????????????? "??????", "RM",
???? Continue home medications
24Prescribing Errors
????????????????
8.1 ??????????????????????????? RM, ??????,
???? " continue home medications"
25Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
9. ???? "hold" order ?????????????????????
26Prescribing Errors
????????????????
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)
27Prescribing Errors
?????????????????
I. ???????????????????????????? prescription
10. ????????????????????? ????????????????????????
?? ????????????????????????????????????????
?
28Prescribing Errors
????????????????
10.1 ?????????????????????????????????????????
???????????????????? ???? beeper
??????????? ????????? 10.2
?????????????????????????????????????????
??????????????????????
29Prescribing Errors
?????????????????
II. ?????????????????????????????????????????
1. ?????????????????? 2. ????????????????????
physician's order sheet ????? 3.
????????????????? ???????????????????????????????
4. ????????????????????????????????????????
30Prescribing 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
31Prescribing Errors
?????????????????
III ????????????????????????????????????
1. ??????????????????????????? 2.
?????????????????????????? 3. ???????????? drug
interaction ??????????????? 4.
????????????????????????????? ????
??????????????? ????????? DVT ????
preoperative prophylactic antibiotics
32Prescribing Errors
????????????????
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 ?????????????????
33Prescribing Errors
?????????????????
III ????????????????????????????????????
5. ?????????????? contraindication
???????????????????? ???? ?? sulfa ?????????
G6PD ???? beta-blocker ??????????????? 6.
???????????????????????????? ??????????? cross
reaction ???????????????????? 7.
???????????????????????????????????? ?????????
34Prescribing 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
35Prescribing Errors
?????????????????
IV ??????????????????????????????????
36Prescribing Errors
????????????????
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
37Prescribing Errors
????????????????
IV ????????????????????????????????????????
patient care team ???????????????
6. ?? List ??? High-alert drugs 7.
?????????????????????????????????????????????????
8. ?? Protocol ???? order sets
????????????????????? ???? anticoagulants,
chemotherapeutic drugs ???????
38Prescribing Errors
?????????????????
V ?????????????????????????? Human Factors
1. ??????????????????? ???????????????????????????
?????? 2. ?????????????????????????????????? 3.
???????????????????????????? prescription ????
???????????????????? ???????????????????????
??????? 4. ??????????????????????????????? ????
?????? ????????????????????????
????????????????? ???? ??????????????????
(Disruptive Behaviors) ?????????? 5. ????? dose
???????????????????????????????????????
?????????????? ???? ?????????????
39Prescribing Errors
????????????????
V ???????????????????????????? Human Factors
1. ?????????????? ????????????????? ????
????????????????????????? 2. ?????????????????????
????????????????????????? 3. ?????????????????????
??????????????????? ???? ????????????
??????????? 4. ???????? policy ???????????????????
??????????????????? ??????????? ????????????
disruptive behaviors ????????????? (Code of
conducts) 5. - ???????????? dose ?????????
weight-based ???????? - ?????? computer
?????????????? - ????????????? confirm
???????? dose ??
40Prescribing Errors
?????????????????
VI ???????????????????????????????
- ?????????????????? - ???????????????
41Prescribing Errors
????????????????
VI ?????????????????????????????????????
- ????????????????? - ???????????????
42Prescribing Errors
?????????????????
VII ??????????????????????? (Mis-identification
of patient)
- ??????? - ??????????????????????
43Prescribing Errors
????????????????
VII ????????????????????????????????????????
(Correct identification of patient)
1. ??? 2 ????????? (2 identifiers) ????????
??????? ????????????????????? Hospital
Number 2. ?????????????????? ????
?????????????????? 3. ????????????????????????????
????????????????????? ??????? coma ????????? 4.
?????? ???/ ???? bar code ?????? 5. ????? 2
??????????????????????????????????????????????????
?????????????? ????????
44Monitoring Errors
?????????????????
1. ??????????????????????????????????????
??????????? ?????????????????????????????????????
???? ?????????? Opioid ???? Sedative
?????????? Monitor respiratory rate ???? O2
Sat
45Monitoring Errors
?????????????
1. ????? Monitor ????? ??? follow up
????????????????? ?????????????????????
???????????????????????????
46Monitoring Errors
?????????????????
2. ??????????????????????????? ???????????????
???????????????????? ????????? ????????
???? ??????? BUN, creatinine ????????
nephrotoxic drugs, ??????? Liver function tests
??????????????? statin ???????????blood level
????? ???????
47Monitoring Errors
?????????????
2. ?? Protocol ?????? laboratory monitoring
blood levels, kidney function ???? liver function
??? lab tests ????? ?????????????
48Monitoring Errors
?????????????????
3. Technique ?????????????????????? ????
??????? existing IV Line ??????? lab
???????????
49Monitoring Errors
?????????????
3. ???????????????????????????????? ????
body fluid ????? ??????? laboratory tests
50Monitoring Errors
?????????????????
4. ????????????????? ??? ??????????????????
critical lab results ??????????????
51Monitoring Errors
?????????????
4. ?? protocol ?????????????????? report critical
lab results ????????????????????????????
52Monitoring Errors
?????????????????
5. ??????????? review ?? Labs ?????????????????
53Monitoring Errors
?????????????
5. ???????????????? labs ?????????????? ???
review lab results ???? ??? ?????????
??????????
54Monitoring Errors
?????????????????
6. ????? protocol ???????? ??? monitor
?????????????????????
55Monitoring Errors
?????????????
6. ?? protocol ??????????????? ??? monitor
????????????????????? 6.1 ??????? sedatives
????????????? conscious, moderate, ???
deep sedation 6.2 insulins 6.3 narcotics
6.4 anticoagulants
56Monitoring Errors
?????????????????
7. ?????????????? monitor medication errors
incidents
57Monitoring Errors
?????????????
7. ?????????????????????? medication error
incidents ??????? incident reports, root
cause analysis ??? corrective actions
58