Academic Day Seminars

ADS – Medication Safety

Today we had an ADS about medication safety, which was very interesting. Especially given that I have encountered some medication errors thus far in my residency (see procedure logs for PSLS’ & incidence/ADR reporting).

Some interesting things I learned today are:

ISMP Canada Definitions:
Adverse Drug Event: an injury from a medicine or lack of an intended medicine. Includes adverse drug reactions and harm from medication incidents. The patient had an adverse event to a medication that was intended to be given that way (e.g. NSAIDs and AKI)

Medication Incident (Medication Error): Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Here the patient received the medication in an unintended way (e.g. too high of a dose, too frequent, wrong drug, etc.) and subsequently had an adverse drug reaction.

Near Miss or Close Call: An event that could have resulted in unwanted consequences, but did not because either by chance or through timely intervention the event did not reach the patient.

  • There are more errors in tertiary care centres then in community hospitals, could be in part due to: learners galore, more complex and “fragile” patients
  • Prescribing accounts for ~50% of sources of medication errors.

Human factors to why we make mistakes:

  • Attentive (problem-solving) mode:
    • Application of rules
    • Use of stored knowledge
    • Slow, methodical thought processes
  • Schematic (automatic) mode
    • Unconscious thought
    • Parallel processing
    • Rapid, effortless
    • E.g. driving home on “autopilot”

This reminds me of a quote one of my preceptors once told me: “experience gives you the confidence to make the same mistakes time and time again”

Some systems in place to help prevent medication errors:

  • Safety culture (no blame culture vs. “just culture”): “We cannot change the human condition but… we can change the conditions under which humans work”
    • Transparent environment, where errors are reported to avoid a shame & blame culture
    • “Just culture” takes into account that if a person is repeatedly making an error to not justify it as a system problem, but rather identify that and help that individual reflect on the errors and provide additional training to prevent recurrences.
  • Prescribing: computer-order entry, ISMP “bad” abbreviations list, pre-printed protcols
  • Transcribing: pyxis connect (though not that helpful)
  • Dispensing: multiple checkpoints; independent double checks (not seeing the first person’s checks – e.g. calculations; minimizes the bias)
  • Administration: omnicell for picking errors, patient specific/unit dosing (so nurses don’t have to measure out/calculate out patient-specific dosing)
  • PSLS: gather data and look for signals/trends or where severe incidents occur so that we can assess if there’s any need for changes in the system to help prevent a recurrence.
  • ROPs: required organizational practices (e.g. concentrated electrolytes – e.g. potassium cannot be stored in patient care areas without additional approval from PT&N). If you as an organization (e.g. BCCH) fail an ROP then you do not get accreditation

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