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No
“A medication error is any Advers event: Any untoward
e
medical occurrence that may
preventable event that may cause present during treatment with a
or lead to inappropriate pharmaceutical product but
medication use or harm to a which does not necessarily
patient.”(FDA Definition) have a causal relationship with
"A medication error is any this treatment.
preventable event that may cause Total number of medication errors in a Advers drug reaction: A
e
or lead to inappropriate month X 100 response to a drug which is
medication use or patient harm Total number of discharges and deaths noxious and unintended and
while the medication is in the in that month which occurs at doses
control of the health care normally used in man for
professional, patient, or prophylaxis, diagnosis, or
Percentage of consumer. Such events may be therapy of disease or for the
1 medication errors. related to professional practice, modification of physiologic
health care products, procedures, function.
and systems, including
prescribing; order Therefore ADR = adverse
communication; product event with a causal link to a
labeling, packaging, and drug
nomenclature; compounding;
dispensing; distribution; Adverse drug event: The FDA
administration; education; recognizes the term adverse
monitoring; and use."-{ The drug event to be a synonym for
National Coordinating Council adverse event.
for Medication Error Reporting
and Prevention (NCC MERP)} In the patient safety literature,
Errors with medication can arise the terms adverse drug event
and adverse event usually
due to a number of factors. Some denote a causal association
of the most common causes of between the drug and the
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these devastating mistakes event, but there is a wide
include the following: spectrum of definitions for
these terms, including harm
Doctor failure to note caused by a
potential drug interactions • drug
(Adverse event) • harm caused by drug use,
and
Packaging and Labeling—
• a medication error with or
Medicine packaging and/or
labeling can cause confusion, for without harm
different medications may look
Institute of Medicine: “an
the same.
injury resulting from medical
Similar Drug Names—Look intervention related to a drug”,
which has been simplified to
alike and sound alike drug
“an injury resulting from the
names can cause one product to
be mistaken for the other. For use of a drug”
the most current USP Use Adverse drug events extend
Caution Avoid Confusion beyond adverse drug reactions
Similar Drug Names, list, visit to include harm from
www.usp.org/patientSafety/brief overdoses and under-doses
sArticlesReports/ qualityReview usually related to medication
errors.
Medication Orders— A minority of adverse drug
Prescribers’ illegible events are medication errors,
handwriting can result in and medication errors rarely
misinterpretation and incorrect result in adverse drug events.
transcription of written
medication orders.
Abbreviations—Health care
providers often use abbreviations
for drug names and/or directions
for use. While abbreviations
save time, they can be
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misinterpreted. Using an
abbreviation for a drug name can
lead to a patient receiving the
wrong drug. Using an
abbreviation of a direction can
result in a patient taking the
medicine the wrong way.
* Incorrect / incomplete medical
evaluations
* Rushed attempts to treat as
many patients as possible
* Administration or prescription
of incorrect drug or dosage
* Administrative errors
* Lack of communication
Total number of transfusion reactions It is mandatory that the
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shoving, by or with another
person
below ground level, ie into a
hole or other opening in
surface
Patient Falls: Unplanned descent
to the floor with or without
injury to the patient
A pressure sore is a lesion that * Braden scale for predicting
develops on the skin and pressure ulcer risk explained
underlying tissues due to below
Incidence of bed unrelieved pressure usually over Number of patients who develop new
a bony prominence. The skin and /worsening of pressure ulcer in a given X
sores after tissues rely on an adequate blood month
8 admission supply for oxygen and nutrients. Number of discharges and deaths in that 100
When tissues are compressed for month
an extended period from hours to
days, blood supply can be cut
off, leading to development of a
sore.
The organization has a process to identify and to report medication errors and near misses. The process includes defining a medication error
and near miss, using a standardized format for reporting, and educating staff on the process and importance of reporting. Definitions and
processes are developed through a collaborative process that includes all those involved in the different steps in medication management.
The reporting process is part of the organization’s quality and patient safety program. The reports are directed to one or more individuals
who are accountable for taking action (also see QPS.7). The program focuses on preventing medication errors through understanding the
types of errors that occur in the organization and in other organizations and why near misses occur. Improvements in medication processes
and staff training are used to prevent errors in the future. The pharmacy participates in such staff training. (JCI)
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BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK
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in assistance. During a move skin independently and has sufficient muscle
moving. Complete lifting without sliding probably slides to some extent against strength to lift up completely during move.
against sheets is impossible. Frequently sheets, chair, restraints, or other devices. Maintains good
slides down in bed or chair, requiring Maintains relatively good position in chair or position in bed or chair at all times.
frequent repositioning with maximum bed most of the time but occasionally slides
assistance. Spasticity, contractures, or down.
agitation leads to almost constant friction.
TOTAL SCORE
(Addressograph)
Perform Braden Scale on admission, quarterly, after major change, after return from Hospital
When Braden Scale Score 16 or less, implement Pressure Ulcer Prevention Protocols
1) Circle type of pressure reduction device used:
State Air, Alternating Pressure, Low Air Loss Mattress, Other ____________ Date: _______ Initials: ________
2) Nutritional Consult ordered: Date: _______ Initials: ________ Date: _____ Initials: _______
3) (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk)
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