Safety Errors and Improvements

Support Materials

Slide Presentation

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Recommendations to Help Minimize Adverse Events and Reduce Risk

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  1. Educate patients: informed patients can improve compliance and alert you to problems before they become more serious.
  2. When prescribing medications that require special precautions, give the patient written instructions; patients do not always remember what you tell them.
  3. Patient-centered care takes into account how the proposed medication regimen will affect the patient's lifestyle. In some cases, a different dosage form or an entirely different product may be appropriate.
  4. Provide a written list of side effects for all medications you prescribe.
  5. Enlist a family member or friend to supervise a patient's at-home medication regimen.
  6. Involve clinical pharmacists in educating patients whenever possible.
  7. Establish log sheet that allows you to track medication, dose, refills, and last labs.

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References

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  1. Bates DW, Spell N, Cullen DJ et al. The Costs of Adverse Drug Events in Hospitalized Patients. Journal of the American Medical Association, 1997; 277: 307-11
  2. Bates DW, et al., Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical Association, 1998, 280:1311-13a
  3. Bootman JL, Harrison DL, Cox E. The Health Care Cost of Drug—Related Morbidity and Mortality in Nursing Facilities. Archives of Internal Medicine, 1997; 157: 2089-96.
  4. Classen DC, Pestonik SL, Evans RS, Lloyd JF, Burke JP. Adverse Drug Events in Hospitalized Patients. Journal of the American Medical Association, 1997. 227:301-6.
  5. Cohen M. Is automation the universal remedy for preventable adverse events? ISMP Medication Safety Alert. 2000;5 (6):1-2.
  6. Rothschild JM, et al. Analysis of medication-related malpractice claims: Causes, preventability, and costs. Archives of Internal Medicine. 2002;162(21):2414-20

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Facilitator's Guide and Outline

A full outline of the key messages for this module, including links to slides, references, and facilitation tips.

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Video

First, Do No Harm

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Facilitation Tips

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  1. Where could you spend it?

    Ask participants to describe what could be done, in the health care environment, with the billions of dollars lost to medication errors.

  2. Why must we pay?

    Ask participants why they think medication-error cases result in payment more often than other malpractice cases.

  3. Who’s at fault?

    Before displaying any data (e.g., Slide 10) regarding defendants, ask participants who they think is most often at fault in medication errors.

  4. What’s on your list?

    Before displaying the list of Human Factors (Slide 17) and Systems (Slide 18) ask participants to list the HF and systems they think increase risk for medication errors.

  5. What does that say?

    Display examples of illegible handwriting (preferably prescriptions) and see if participants can decipher them. List how many different interpretations they come up with.

  6. What do I know?

    Ask participants to (privately of course) list any medications they are currently taking. For each, have them assess whether they are fully informed about the purpose, risks and benefits, side effects, renewal policy, etc. Ask them to volunteer any (non-embarrassing) insight this provided.

  7. Disclosing an error

    See Disclosure of Unanticipated Outcomes

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Exercise

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Resident's Module: Medication Safety - Teaching Notes

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