Manual Preventing Medication Errors and Improving Drug Therapy Outcomes: A Management Systems Approach

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There will also be a question and answer session following the CE session. NABP is the independent, international, and impartial Association that assists its member boards and jurisdictions in developing, implementing, and enforcing uniform standards for the purpose of protecting the public health. A validated Statement of Continuing Pharmacy Education Credit will be sent as proof of participation within approximately six weeks.

Stalinists thought their system was perfect but that people kept trying to sabotage it. We see modern health care in the same way: as a perfect world except for the people messing it up. In reality, it is the opposite. The world is full of hazards, and people actually work to make it safer. One of the classic examples of a systems failure is in cases of drug- drug reactions. Any resulting adverse reaction often leads to finger-pointing.

In terms of automation, observational studies have found that hour dispensers or storage cabinets often are checked less frequently as technology has advanced. Failures beget complexity Cook says organizations tend to react to failure by "blaming and training. Those interventions can make the system even more complex and introduce new forms of failure. The whole cycle then repeats itself.

Use of Health IT To Reduce Medication Errors and Improve Patient Safety

The point is not to add another layer of protocol, but to see where the existing system failed, he explains. Many of the things we often propose to do have side effects, like computer order-entry systems, bar coding, things like that.

Healthcare Quarterly

They can improve system performance, but they come with their own problems as well. One of the first major documents to shed light on the pros and cons of automation and medication errors as part of the systems analysis was the White Paper on Automation in Pharmacy, which was detailed in the February issue of Drug Utilization Review. The document was commissioned by a coalition of seven national pharmacy organizations.

We know the visual identification of drugs is made more difficult when you switch suppliers, but we switch suppliers all the time. What effect each possible change will have on safety is the subject of hot debate. The agency often is asked to perform systems analyses of the medication process for health care organizations.

ISMP has identified 10 common weaknesses in medication systems and categories that include patient information; drug information; communication of drug information; labeling, packaging, and drug nomenclature; drug storage, stocking, and standardization; drug device acquisition, use, and monitoring; environmental stressors; competence and staff education; patient education; quality processes; and risk management.

ISMP president Michael Cohen says when his agency goes into a hospital to do a systems analysis, every facet is covered. We speak to everyone: nurses, doctors, and phar macists.

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We go into the operating rooms, we go through the computer system, we look at all the records to see how well they are communicating drug orders. We focus on the system, not the staff. It is a completely objective review, which is very helpful. Figures and Tables. Citations Publications citing this paper.

Joseph Guglielmo. Inappropriate prescribing, non-adherence to long-term medications and related morbidities : Pharmacoepidemiological aspects Khedidja Hedna.

Medication Errors in Acute Cardiovascular and Stroke Patients | Circulation

Medication safety knowledge, attitude, and practice among hospital pharmacists in Lebanon. Causality and preventability assessment of adverse drug events of antibiotics among inpatients having different lengths of hospital stay: a multicenter, cross-sectional study in Lahore, Pakistan Anum Saqib , Muhammad Rehan Sarwar , M.

Sarfraz , Sadia Iftikhar. Safe and effective use of medicines for patients with type 2 diabetes - A randomized controlled trial of two interventions delivered by local pharmacies.

References Publications referenced by this paper. Quality assurance to quality improvement: measuring and monitoring pharmaceutical care. David M. Ingram , Diane M.