Medication Management

Suggestions

Suggestions for Presentation

  1. Examine one or more case examples to see if participants understand where things went wrong, and if they recognize similar risks in their own workflow.
  2. Following the medication path from order to administration, ask participants where they see risk in their day-to-day work and what they might do to minimize errors.
  3. Divide participants into two groups, one representing human factors and the other representing systems. Introduce one or two case examples and have each side identify what went wrong and what might be done to avoid similar errors.
  4. Present to teams composed of representatives from each step of the medication process (e.g., ordering MD, pharmacist, pharmacy technician, floor nurse, etc.)

back to top

Suggestions for Customization

Additional Presentation Materials

  1. PowerPoint slide presentation

Additional References

  1. Anonymous. A study of physicians' handwriting as a time waster. Journal of the American Medical Association. 1979;242:2429-30.
  2. American Medical News Nov 22/29, 1999.
  3. Col et al: The role of medication non-compliance and adverse drug reactions in hospitalization in the elderly. Archives of Internal Medicine. 1990;150:841-45.
  4. 37 Fed. Reg. 16, 503 (1972)
  5. Cardwell M. Preventing perinatal early-onset of GBS: the new standard of care. Journal of Legal Medicine. 1997; 511.
  6. Rayburn WF and Farmer KC. Off-label prescribing during pregnancy. Obstetrics and Gynecology Clinics of North America. 1997:24(3);471-78.
  7. Cohen MR (Editor) Medication Errors. American Pharmaceutical Associations ISBN: 0-917330-89-7.
  8. Handheld prescribers: do digital scripts make sense, Medical Economics September 2000.
  9. Freudenheim MH. Digital doctoring, New York Times, January 8, 2001.
  10. Smitze A. Do no harm. Online Learning, March 2001.
  11. ASHP Survey gives medication use snapshot, ASHP News and Views. 2001;34 (3).
  12. Rothschild JM, et al. Survey of Physicians’ Experience Using a Handheld Drug Reference Guide, from Converging Information, Technology and Health Care, Proceedings from the 2000 AMIA Annual Symposium.

Additional Subject Matter Experts

  1. Tejal Gandhi, MD, MPH, Director of Patient Safety, Brigham & Women's Hospital, Boston, MA.
  2. David Bates, MD, MSc, Chief of the Division of General Medicine at Brigham & Women's Hospital in Boston, MA.

back to top

Suggestions for Measurement of Competency in the Objectives

  1. Assess participants ability to articulate the seriousness of medication errors in terms of their impact on injuries to patients and financial impact on providers
  2. Assess participants ability to list the common causes of medication errors
  3. Assess participants ability to demonstrate communication skills aimed at reducing medication errors
  4. Assess participants ability to describe technological solutions to key medication error problems

back to top

Additional Information

back to top