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PHARM BASICS, OTC, HERBALS & DIETARY SUPPLEMENTS -EXAM 1 STUDY GUIDE

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MEDICATION ERRORS: PREVENTING & RESPONDING “TOO ERR IS HUMAN” • 1999 report by Institute of Medicine (IOM) • Brought medical errors to the public’s attention • Preventable errors were ... responsible for 7000 deaths per year. • 3% to 6.9% of hospitalized patients experience a medication error. • Two follow up reports from the IOM found no significant change in rates of preventable errors. • In a 2006 IOM study, it was estimated that some form of medication error resulted in harm to 1.5 million patients PREVENTING • Most medication errors occur as a breakdown in the medication use system, as opposed to being the fault of the individual. • Key to preventing errors: • Reporting of errors • Reporting of potential errors • Nonpunitive approach to error reporting or “Just Culture” • QSEN initiatives • Adverse drug events • Many caused by Medication errors • Adverse drug responses (ADRs) • Allergic reaction (often predictable) • Idiosyncratic reaction (usually unpredictable) • Defined as any abnormal and unexpected response to a med, other than allergic reaction that is peculiar to an individual patient ADVERSE DRUG EVENTS: intersection of Med Error with Adverse Drug Events MED ERRORS • Preventable • Common cause of adverse health care outcomes • Drugs commonly involved in severe medication errors: central nervous system drugs, anticoagulants, and chemotherapeutic drugs • More potential for harm with “high-alert” medications • SALAD (sound-alike, look-alike drugs) • LASA (look-alike, sound-alike) • Example: buspirone and bupropion & prednisone and prednisolone ISSUES CONTRIBUTING TO ERRORS • Errors can occur during any step of medication process • Procuring • Prescribing • Transcribing • Dispensing • Administering • Monitoring • Organizational issues • Educational system issues • Sociologic factors • Use of abbreviations “NEAR MISS” VS “CLOSE CALL” • Near Miss - Event or situation that did not produce patient injury, but only because of chance • Close Call - An event or situation or error that took place but was identified and captured prior to reaching the patient [Show More]

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