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- Simple steps to reduce medication errors | Article | NursingCenter.
Zoom Zoom. Availability Usually despatched within 2 weeks. With Free Saver Delivery. Facebook Twitter Pinterest Share. Description The supply and administration of medicines is an area of practice in which a number of healthcare professionals e. Prescribing is a relatively new role which many of these healthcare professionals have adopted. Medication Safety focuses on promoting safety in the delivery of medicines. And third, it was not possible to justify non-labeling behavior with clinical, ergonomic, or economic arguments. As a result, Virginia Mason developed an explicit, standardized process for medication labeling.
The process is now used throughout the organization. Caplan noted that this event and its associated lessons have accelerated the implementation of other related safety strategies. She described the national survey of CRNA training programs she and 2 colleagues conducted regarding formal training in anesthesia medication safety practices.
Results revealed the impression that drug errors observed or committed by CRNA students are under-reported and that medication safety can be a stronger component of the curriculum. Support was generated through the survey process for a nationally standardized curriculum as well as generous use of simulation to teach safety skills for medication administration to CRNA students.
Jerry A. Cohen, MD , first vice-president of the American Society of Anesthesiologists and from the University of Florida, stated that fragmentation of the approach to medication safety problems is itself a significant problem. He maintained, the Swiss-cheese model of human error and accidents notwithstanding, that attempting to isolate root causes obscures complex interactive pathways system function that lead to errors. He cited a host of individual factors that can contribute to medication errors, particularly failure to standardize the operating room environment, especially the anesthesia work area, which leads to chaos and distraction and an equally long list of barriers to improvement, especially resistance to checklists, communication silos, and production pressure.
Cohen suggested that widespread standardization and also the use of pharmacy-prepared bar coded medications with bar code readers as part of electronic anesthesia records and information management systems would be central to efforts to improve medication safety in the operating room. He concluded with a plea for studies to generate data to guide implementation and also stimulate appropriate standards and regulations that will govern practice.
A different take on human factors engineering was provided by John W. More emphasis came on the context of medication use in the work area than on labeling itself.
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He suggested that very simple factors such as strict standardization of the anesthesia work space, especially the location of stored medications, would help improve safety now while more complex technologic solutions involving barcodes, readers, and computerized records are developed and rigorously tested for efficacy.
Also, Ms. Foster noted the trend of greater integration of health professionals, physicians in particular, into the internal institutional organization, which should increase the receptivity of administrators to safety proposals. At the outset, he noted the tension and complex interaction between human error and system failure and how this could relate to different types of medication errors wrong drug or dose or route, and adverse reactions. He also applied the STPC paradigm to each case to dissect out causes that could be corrected with those elements.
In all cases, there were both human factors and system components as root causes. In nearly all the cases, standardization of practice and protocols would have helped to prevent the error. The eerily familiar theme of accidental injection of a toxic substance into an inappropriate injection port with catastrophic outcome figured in 3 of the cases. Adherence to strict labeling policies and physical segregation of toxins were the suggested remedies. Vaida, PharmD , its executive vice president.
The ISMP focus is on the system causes of medication errors and resulting system changes that must be implemented along with education to prevent recurring patterns. Vaida stressed employing an open environment of sharing errors internally and externally to safety organizations for learning, sharing, and bringing about change.
Critical Conversations for Patient Safety: An Essential Guide for Health Professionals
He noted relatively poor compliance with labeling policies and procedures during drug administration and also showed many examples of striking look-alike drug vials and noted the disproportionately great number of look-alike accidents involving muscle relaxants. He also stressed that clinicians working to achieve consensus with pharmacists and manufacturers need to establish and accept a relatively limited set of standardized concentrations for drugs.
At a national consensus conference on the safety of intravenous drug delivery systems, there was a clear preference for manufacturer-prepared completely ready-to-use IV medication in all settings, although increased cost and potential inapplicability such as for seldom-used but necessary drugs in the anesthesia operating room armamentarium are drawbacks of that approach if standardization is not agreed upon. Vaida also noted a clear preference for satellite pharmacies in operating room suites but noted that when that is not possible, there must be organized involvement from pharmacy for anesthesia services in the operating room to support medication safety.
Philip J. Schneider, RPh , associate dean of the University of Arizona College of Pharmacy, noted that evidence-based best practices known to improve medication safety, particularly unit dosing, have been in place for medication administration in hospitals for decades, but those concepts are not applied in the operating room. He noted that all of the key parts of the medication administration process prescribing, transcription, dispensing, and administration—the points at which mistakes occur are the responsibility of the anesthesia professional in the operating room, preventing the traditional safety checks present in other settings.
Patricia C. However, she asserted that color-coding of medication containers may not be a help and may actually be a detriment in some cases. Andrew J. Donnelly, PharmD , director of Pharmacy at the University of Illinois Medical Center at Chicago, emphasized that cost of medications and associated personnel is a huge issue today for health care institutions facing budget constraints. Further, he also noted that the unique medication use process for anesthesia in the operating room has minimal involvement of pharmacy and lacks the normal checks and balances.
This would involve allergy verification, dissemination of drug information, formulary management, facilitation shortages; look-alike, sound-alike , quality improvement projects, and even research projects.
He also favored standardization of medications and concentrations, throughout an institution and even across the entire industry. Noting that the operating room is the most medication-intensive area of the hospital, Ms. Benjamin suggested that now is a great opportunity to coordinate what anesthesia professionals want medications ready to use, readily available, and easy to store, identify, administer with what pharmacists want effective evidence-based processes that are efficient, safe, and compliant with regulatory and accreditation standards and that promote safety through standardization, best practices, security, and control.
An example of a safety initiative that could be adapted to operating room medication safety concerns was offered by Bruce D. SCA is engaged in a comprehensive longitudinal project to study every conceivable aspect of cardiovascular anesthesia practice utilizing real-time observation as well as literature review to determine why errors occur and develop best practices with check lists emphasizing systems, human factors, and the team approach to prevent those errors. A parallel project for operating room medication safety improvement was proposed that would utilize the same design.
Figure 1. Look-alike medications; left medication is dexamethasone and right vial is glycopyrrolate. A more direct example was presented by Wilton C. This syringe bar code is easily integrated with AIMS so that at the time of administration, the bar code is scanned to confirm the drug name and concentration, patient allergies, if the syringe has expired, and if the syringe has already been used for another patient. Levine detailed how this system can also be integrated as the safety system for seamless use with ready-to-use prefilled syringes.
He noted that in his institution where some rooms have the technology and others do not, practitioners who have worked with the system always request to be assigned to rooms with the computerized system. Professionals access system data directly with no need to send files. There are also safety systems that warn against toxic doses, allergic and cross-reactions, drug interactions, duplication of therapeutic classes, contraindications, and adverse effects.
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Automation using bar codes allows drugs to be checked when dispensing and administering the drug;. The individualized drug-dispensing system has advantages, such as the possibility of reviewing medical prescriptions, increased control over drug use, less inventory in hospital units, reduced theft and losses, and individual patient invoicing.
The disadvantages are the high rates of dispensing and delivery errors that still exist, the time spent by nurses calculating and preparing drug doses, increased expense regarding human resources and materials, and high losses due to theft and inadequate drug delivery. Usually, the pharmacy is present in hospital units.
Pharmacy assistants replenish emergency stocks daily, collect prescriptions for the day, collect drugs returned from the previous day, and send drugs for the following 24 hours of treatment. On a monthly basis they also check drug validity in the inventory and unauthorized inventory.
Pharmacists visit hospital units daily to supervise work done by their assistants. They also help nurses clarify doubts related to drug delivery and stability as well as storage and use of heat-sensitive and photo-sensitive drugs. Pharmacists also discuss prescription issues with physicians. In hospitals with adequate human resources allied to professional and institutional interests, pharmacists develop clinical activities with the professional health team to reduce medication errors. The mixed dispensing system combines the collective and the individualized systems and is also used in Brazilian hospitals.
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