Administration medication errors prevention

Medical errors—Prevention. 2. Health facilities. [DNLM 1. Medical Errors—prevention control. 2. Safety Management—organization administration. 3. Health Facilities—organization administration. 4. Organizational Innovation. 5. Truth Disclosure. WX 185 M831t 2004]... 

Medical errors—Prevention. 2. Health services administrators. 3. Patients—Safety measures. 1. Hidley, John H. II. Title. 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including prescribing order communication product labeling, packaging, and nomenclature compounding dispensing distribution administration education monitoring and use. 

The lack of photoprotection for the drug product during administration may lead to increased/decreased efficacy or increased toxicity of photolabile drugs. These episodes may be categorized as preventable medication errors, in particular, as wrong administration-technique errors (2). On the other hand, superfluous photoprotection measurements represent an unproductive use of nurses time and a waste of materials. 

Reason (21) has described a model for looking at human error that portrays a battle between the sources of error and the system-based defenses against them. This model is often referred to as the "Swiss cheese model" because the defenses against error are displayed as thin layers with holes that are described as latent error in the system. Figure 26.5 demonstrates the model as applied to medication error. Each opportunity for error is defended by the prescriber, pharmacist, nurse, and patient. When a potential error is identified and corrected (e.g., dose error, route of administration error) the event becomes a "near miss" rather than an ADE. In those cases in which the holes in the Swiss cheese line up, a preventable medication error occurs. The Swiss cheese model provides an interesting framework for research in this field. 

Name four ways to prevent common medication administration errors. 

Prescriber Order Entry Module (POEM ) provides a database of the most common medication orders. These orders are specific to drug, route of administration, formulation, age, indication/use, and weight or body surface area, if applicable. This enables more accurate and efficient point-of-care computerized order entry applications to prevent errors at the prescribing stage of drug delivery. 

Richard M.J. Bohmer is a physician and an Assistant Professor of Business Administration at Harvard University. His research focuses on the management of clinical processes and the way in which health-care teams learn to improve outcomes, prevent error, and reduce adverse events. He has studied catastrophic failures in health care, the adoption of new technologies into medical practice, and more recently the way in which health-care delivery organizations deal with custom and standard operations concurrently. He holds a medical degree from the University of Auckland, New Zealand, and an MPH from the Harvard School of Public Health. 

The possibility to develop a surgical site infection depends on bacterial colonization of the operative field. Perioperative antibiotics are central to prevent postoperative surgical wound infection [15]. To reach the best effect, timing of administration of the single-shot antibiotic prophylaxis is crucial 30-60 min before skin incision is adequate. Errors due to too early or too late medication put the patient at risk for an infection. 

---