3. Medication errors Flashcards
Definition of medical errors?
Anypreventableevent that may lead to inappropriate medication use or patient harm while the medication is in the control of the health-care professional or patient
Examples of medical errors
Drug interactions
dosing errors
wrong route of administration
How to system factors contribute to medication errors?
working hours of prescribers
distractions
availability of information- patient records
checking routines/guidlines
How does the prescriber contribute to medical errors?
- Knowledge- of drugs in common use & therapeutic problems encountered
- Skills- taking good drug history, communicating w/ patient, numeracy
- Attitudes- checking routines & monitoring of prescribing
What is human error theory?
describes 4 different types of errors- slip, lapse, mistake, violation
Slips & lapse are untented errors- correct plan known but not executed due to world load or pressure
Mistakes & violation are intended errors- wrong plan selected due to poor training
Slip- an action that does not occur as planned- presumption not as intended
lapse- action is missed or someone forget to do something e,.g. prescription incomplete or forgotten
Mistake- when someone does something they think is correct but isn’t due to lack of knowledge
Violation- deliberate or illegal action is undertaken
How to reduce human error?
minimise distractions
use checklist & guidelines
increase supervision
ensure workers properly trained
How can prescribers identity errors?
using checklist
training to improve prescribing
using computer tools
How can prescribers correct medication errors?
inform patient
inform colleagues
clinical review occurs
report incident so others can learn
How can prescribers reduce medication errors?
cross checking for drug interactions, allergies & suitability of individual
choose lowest effective dose for shortest period
consider non-drug options
recognise high risk situations
