9 - External Medication Error

Question 1

External SOURCES for
medication errors and safety issues

Answer 1

• *MEDWATCH**
• *FDA** safety information & ADE reporting program

Manufacturers & Wholesalers

ISMP

LISTERVS
application that distributes messages to SUBSCRIBERS on an electronic mailing list

Question 2

Manufacturer & Wholesaler

External sources for medication errors and safety issues

Answer 2

DRUG RECALLS
ex.
Paliperidone –> missing laser drilling

if dispensed:
depends on how significant the recall iss

Question 3

ISMP
Institute of Safe medication Practices

External sources for medication errors and safety issues

Answer 3

ISMP Medication Safety Alert

Electronic newsletters for HCP & consumers
Ex.
Acute Care - biweek
Community / Ambulatory Care - monthly
Nurse AdviceERR - monthly
Long-Term Care Adice ER - bimonth
Consumer Safe Medicine - bimonth

Question 4

Vincristine Safety

Answer 4

INTRATHECAL Admin is Uniformly fatal

error has happened BEFORE –> learn from mistake

•IV needle or catheter must be properly inserted prior to injection or infusion

Any leakage into surround tissues during the infusion may cause substantial injury.

Question 5

Process Improvement PROCESS

PDSA

Answer 5

Plan Do Study Act

• *P** - Address the issues & engage stakeholders to ensure concerns
• *enhance effectiveness** & buy-in to proposed system solution

Consider the hierarchy of interventions

D - Implement system solution + education

S - Monitor

A - Ensure compliance + modify processs when neeed