Safety Errors and Improvements

Facilitator's Guide and Outline

Rationale

ADEs are the number one medical error and impact a significant portion of patients and providers

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Grabber

While 75 percent of CRICO claims are closed without payment, only 50 percent of medication error-related cases close without payment.

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Definitions

  • Medication error
  • Adverse Drug Event
  • Potential Adverse Drug Event

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Key Message #1

Understand the magnitude of medication errors

  • National impact/costs
  • CRICO impact/costs
  • At-risk population
  • Inpatient v. outpatient

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Key Message #2

Understand the most common causes of medication errors

  • Human error
  • Systems
  • Handwriting
  • Abbreviations
  • Oral orders
  • Look-alike and sound-alike drugs
  • Dosage calculation
  • At-risk population
  • At-risk drugs

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Key Message #3

Understand how better communication reduces medication errors

  • Establishing expectations and responsibilities
  • Explaining the risks
  • Explaining how to take drugs
  • What to do if side effects occur
  • Disclosing errors

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Key Message #4

Understand how technology can reduce medication errors

  • Advantages of CPOE
  • Disadvantages
  • Handhelds

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Key Message #5

Understand what else can help us reduce medication errors

  • Off-label
  • Other

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Summary

  • Understand the scope of the problem in your work setting
  • Identify patient groups and drug therapies at greatest risk in your practice
  • Design / track medication processes that minimize the opportunities for adverse events

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