Programming error prevention

The focus of MANAGER is somewhat different, in that it was primarily developed to provide a numerical output for use in risk assessment. Nevertheless, the qualitative dimensions included in the audit trail will undoubtedly provide information which can be used as part of an error prevention program. 

Multidisciplinary educational programs should be developed for health care personnel about medication error prevention. Because many errors happen when procedures are not followed, this is one area on which to focus through newsletters and in-service training. It also is important for pharmacy staff not just to focus on their own internal errors but also to look at other pharmacies errors and methods of prevention and to learn from them. Organizations such as the ISMP, USP, and many others provide ongoing features to facilitate these reviews in publications such as Hospital Pharmacy, Pharmacy Today, U.S. Pharmacist, and Pharmacy and Therapeutics or newsletters that report on current medication safety issues and offer recommendations for changes. 

The underlying emphasis of the program is the enhancement of team performance in the medical environment. All members of a medical team need to work together as a well-stmctured, well-fimctioiiing team that has as its main aim patient safety. Failure to act as a well-coordinated team that understands all the issues present and conmiunicates freely and accurately can lead to detrimental consequences for the patient. Medical TRM and error prevention training is designed to prevent such occurrences. 

The major limitation of velocity transducers is their sensitivity to mechanical and thermal damage. Normal use can cause a loss of calibration and, therefore, a strict recalibration program is required to prevent data errors. At a minimum, velocity transducers should be re-calibrated every six months. Even with periodic re-calibration, however, velocity transducers are prone to provide distorted data due to loss of calibration. 

Appendix C contains a United States Pharmacopeia (USP) medication errors reporting program form, which is used by health care professionals for sharing information of medication errors to prevent them from occuring again. Also included is text explaining medication error and the USP... 

Prevention of medication errors is the primary objective of the USP Medication Errors Reporting Program. It collects and analyzes potential and actual medication errors submitted by health care practitioners. The program affords health care professionals the opportunity to report medication errors and thereby contribute to improving patient safety by sharing their experiences. 

When action level excursions or frequent alert excursions are identified, a corrective action program, resolution deadline, and preventive plan shall be implemented. Risk analysis shall be performed to determine the probability of one or more causes of errors occurring, as well as to identify the potential consequences of excursions. (See attachment nos. 1700.80(1), 1700.80(J), and 1700.80(K), and 1700.80(L) for excursion of air, surface, personnel, and visual inspection report during the visit to plant by the microbiologist responsible.)... 

This chapter focuses on system enhancements and the checks and balances needed to proactively prevent medication errors as pharmacists and technicians prepare, dispense, and monitor the effects of medications in all practice settings. In addition, focus is placed on the importance of determining latent failures that contribute to mediation errors by developing effective medication error reporting programs to discover how latent failures occur and how they can be prevented. 

A laboratory QA/QC program is an essential part of a sound management system. It should be used to prevent, detect, and correct problems in the measurement process and/or demonstrate attainment of statistical control through QC samples. The objective of QA/QC programs is to control analytical measurement errors at levels acceptable to the data user and to assure that the analytical results have a high probability of acceptable quality. 

Report any information relating to medication errors to the Medication Errors Reporting Program operated by USP convention [10] and the Institute for Safe Medication Practice (ISMP) or other corresponding institutions in the different countries. The program shares information on medication errors with health care professionals to prevent similar errors from recurring. 

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