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Standardize labels, packaging. □ Protected Standard Concentration. □ Anticoagulation Services. □ Counseling. □ Use protocols / smart pumps.
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Basic Medication Safety (BMS) Certification Course King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard – Health Affairs
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Top 10 Medications Reported as Causing Harm
MedMarx 2008 High Alert Meds with Harm Score E and Above
(43%) Harmful Incidents.^ Accounted for 199 / 465 (ISMP Canada; 2001-2005)
Reported Medication Errors / Near Misses for Top Four High Alert Medications
2015, 2016 and 2017 - Central Region (KAMC)
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Antithrombotic Agents
Opiates/Narcotic Agents
Chemotherapeutic Agents
Insulin
2015 2016 2017
Total HAM: 2015 = 527 2016 = 814 2017 = 814
Winterstein, A., Hatton, R., Gonzalez-Rothi, R., Johns, T., & Segal, R. (2002). Identifying clinically significant preventable adverse drug events through a hospital’s database of adverse drug reaction reports. Am. J. Health Syst. Pharm., 59(18), 1742–1749. Retrieved from
Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.
U$3.5 billion is spent annually on extra medical costs of ADEs
DRUG TOO MUCH LEADS TO: Opiates Respiratory depression Insulin Hypoglycemia Anticoagulants Bleeding
44 year old male History of PE on Warfarin
Admitted for bilateral hydronephrosis, with acute renal failure for bilateral nephrostomy tube placement Post-nephrostomy tube the anticoagulation was resumed with Enoxaparin 120 mg q 12 hr in the setting of severely compromised renal function
Patient was transferred to ICU with clinical picture of shock, which turned to be hemorrhagic, complicated by multi-organ failure and death
Ultrasound of abdomen showed evidence of intra-abdominal collection
Standardize labels, packaging Protected Standard Concentration Anticoagulation Services Counseling Use protocols / smart pumps Individualized monitoring and handoffs Medication Reconciliation Improved Information and Counselling for Patients At start of therapy (prescription) On hospital discharge At the first anticoagulant clinic appointment When necessary throughout course of therapy
24% during 2017 at KAMC – Riyadh 23% during 2016 at KAMC – Riyadh
LASA (Morphine and HYDROmorphone) Lack of leading zero Ordered .8 mg , patient received 8 mg Morphine Bolus dose, failing to re-program maintenance dose Different rates and concentrations Improper disposable of Transdermal Patches
18 % during 2017 at KAMC-Riyadh 15 % during 2016 at KAMC-Riyadh
Cases
Drug Error and Outcome Methotrexate Administering daily instead of weekly (approximately 25 fatalities reported) VinCRIStine Accidental Intrathecal administration - Fatal Lomustine Oral agent administered daily instead of every 6 weeks, hospitalization and death CARBOplatin and CISplatin
CISplatin administered at dose intensity appropriate for CARBOplatin, fatal outcome
Miscommunication Total course (or cycle) dose given every day Substantial distance between Pharmacy and patient treatment area (lack of communication) Lack of health care information (labs, BSA) Excessive interruptions LASA / packaging Lack of protocols and education Route of administration: Intravenous vs. Intrathecal
Use of personal protective equipment to reduce employee exposure to hazards Dispense Vin CRISt ine (and other vinca alkaloids) in a minibag of a compatible solution and not in a syringe Weekly dosage regimen default for oral Methotrexate in electronic systems when medication orders are entered. Body Surface Area dosing (mg / m2), when applicable mg / kg Use updated lab information Patient / caregiver education Communication
8% during 2017 at KAMC Riyadh 13% during 2016 at KAMC Riyadh
Look-Alike Vials Use of “U” or “IU” Incorrect dose / rate Lack of dose checking
Stored in Red Bins with Lids Patient care areas: Stored in ADC locked Lidded Crash Cart / Black Box (as applicable) Auxiliary label “High Alert / Conc. Electrolyte: Must Be Diluted” Standardized medication labels
APP 1433-18: Concentrated Electrolytes