Medication errors could kill.
Implementing a medication safety program could save thousands of lives.
This is a summary presentation on how to implement such system
2. Patient Safety is a concern from
• Wrong treatemnt
• Wrong surgery
• Nosocomial infection
• Patient fall
• Infant abduction
• Medications…..
3. The 6 rights are now 8
• Rights of Medication Administration
• 1. Right patient
• 2. Right medication
• 3. Right dose
• 4. Right route
• 5. Right time
• 6. Right documentation
• 7. Right reason
• 8. Right response
4. • PATIENT SAFETY: Most medication errors occur
during drug administration
• Medication Errors occur when the administration 5
or 8 rights are not followed
• The 2006 Institute of Medicine (IOM)1 Report
entitled
• “Preventing Medication Errors” states that
medication errors cause harm to 1.5 million people
each year.
Why Put The Effort
5. Where is the weakest link
• There are many weak links which put the patient at
risk
• Telephone orders
• Verbal orders
• Transfer orders
• Look alike medication
• Poor handwriting
• Loose double checking of medications
• Peri-operative orders
• Many other weak links
6. Implementing Medication Safety is Must
• Medication error could kill..
• All Clinical Staff involved in medication ordering
and subsequent steps must take annual medication
safety training and test
• JCIA and almost all accreditation bodies stress on
patient safety including risk arising from medication
errors
• Beneficial for patient, organization and staff
• Less expenses and law suits
• Better image for the provider
7. How to implement
• Establish a policy
• Include in policy high alert, look alike, high risk,
narcotics, electrolytes medications
• Review transcription process
• Review verification and double witness process
• Review pharmacy actions
• Encourage clarification at all levels
• Communicate the policy
Establish an annual certification program mandatory
to all concerned staff
8. How IT System is Efficient
• Establish a medication safety on-line course
• Establish an on-line quiz
• Make mandatory and prerequisite for re-contracting
• Establish non punitive environment to encourage
reporting system errors
• Encourage Adverse Occurrence Reporting AOR
electronically
• Implement AOR system, paper or electronic
9. Outcome
• Patient safety is increased
• Staff are well prepared
• Adverse Occurrence Reports AORS are being filled
and analyzed, system errors identified
• Quality reports are populated
• Organization image is acceptable
• Less cost on patient and organization
• Improved work environment for staff with less error
care
10. Need Help?
• We have done this program before and we can
help you set it up with acceptable cost compared to
non acceptable loss
• Contact us and we will be happy to put our hands
together for better outcomes
• Hexpert.sharepoint.com
• ssawli@yahoo.com