Medication errors design

Each time a patient moves from one setting to another, clinicians should compare previous medication orders with new orders and plans for care and reconcile any differences. If this process does not occur in a standardised manner designed to ensure complete reconciliation, medication errors may lead to adverse events and harm (IHI MedReconcilliation 2008). Several national organisations round the world have now produced help to reduce errors with medication reconciliation. Some examples are given below. 

USP received a medication error report involving the products Neumega (oprel-vekin) and Proleukin (aldesleukin). Oprelvekin, a recombinant human interleukin-11 product used to stimulate platelet production in selected patients undergoing chemotherapy, is sometimes abbreviated as IL-11. Aldesleukin, a recombinant human interleukin-2 derivative indicated in designated patient populations for the treatment of metastatic renal-cell carcinoma, is sometimes abbreviated as IL-2. 

Since the Council s formation, it has produced several important work products. Among them are the standardization definition of the medication error, the development of a series of recommendations designed to reduce errors in the medication use process, and the... 

While medication errors and medication processes have received most attention, achievements have not been confined to medication safety. Box 11.4 shows an example of a similarly sustained and radical change in the interpretation of radiographs. As so often happens, healthcare processes had evolved and adapted over time, rather than being designed to produce a certain... 

Medication errors involving look-alike/sound-alike drug names can cause serious patient harm. For instance, a number of errors have been reported and published on the confusion between Lamisil and Lamictal . Reading these two names quickly, one can easily see how they could be confused, but re-design of the labels to highlight the differences rather than the similarities makes them markedly distinct (Figure 12.1). 

Hospital B s experience is not unique. The net effect of the completion rate measure has been that it produces data which show that many actions are not completed within a specified time frame. This has, in some hospitals led senior managers to call into question the value of the walk rounds or to drive behaviour to focus on problems that can be fixed easily. Thus the lack of integration of human factors into hospital and medical device design and the allocation of staffing and resources gets put into an unresolvable box and remain latent conditions that continue to create error traps, inefficiencies and poor patient experience. 

Hospital work areas and staff asked to complete the survey When the Hospital SOPS was developed, it was not specifically designed and tested for use with non-clinical staff like those in honsekeeping, facilities, or human resources. Yet once the snrvey was released, it became very clear that hospitals wanted to survey all staff from all units and departments, with the understanding that every staff member plays an important role in ensuring patient safety. By being attentive and aware of patient safety risks, in an environment that encourages open communication and learning, even non-clinical staff can help prevent medication errors, patient identification errors and many other types of errors. Since one of the uses of the survey is as an education and awareness tool, it makes sense for hospitals to conduct the survey in a broad way across units and staff positions. 

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