SLIDE 1
Medication Errors in the United States
Medical errors are the eighth leading
cause of death in the United States
Medication errors account for at least
7,000 deaths in the United States each year
Annual cost of medication errors is
Medication Safety Pharmacist Jackie Biery, Pharm.D. University of - - PowerPoint PPT Presentation
Medication Safety Pharmacist Jackie Biery, Pharm.D. University of - - PowerPoint PPT Presentation
Medication Safety Pharmacist Jackie Biery, Pharm.D. University of Washington February 21, 2006 Medication Errors in the United States Medical errors are the eighth leading cause of death in the United States Medication errors account
SLIDE 2
SLIDE 3
Unlabeled Containers Lead to Patient’s Death – November 2004
A 69y/o Seattle
female died during a cerebral angiography
Accidentally injected
with chlorhexidine (an antiseptic skin prep solution) instead of contrast media
JCAHO adopts new
labeling standards
SLIDE 4
Three Neonates Die from Heparin Overdoses - September 2006
1mL vials of heparin
10,000units/mL were placed in an ADC instead of 1mL vials of heparin 10units/mL
Total of 6 babies affected Similar overdose of heparin
in 2001
Limit concentrations of
heparin stocked in the hospital and pharmacy
SLIDE 5
Role of the Medication Safety Pharmacist
Manage Medication Error Reporting
Review reports submitted through the online
reporting system
Determine root cause of error
SLIDE 6
Harm Score
SLIDE 7
Role of the Medication Safety Pharmacist
Identify best practices for medication
safety
Analyze current practices that contribute to
medication errors
Take proactive steps for prevention Facilitate process and system changes to reduce the
likelihood of occurrence/recurrence of error Educate pharmacy staff and other
clinicians to promote safe medication practices
Develop educational programs to improve medication
safety and regulatory compliance
SLIDE 8
Role of the Medication Safety Pharmacist
Participate in committees related to
medication safety
Safe Medication Practices Committee Patient Safety Committee H.E.A.T. Meetings Medication Reconciliation Committee Use of Two Patient Identifiers Committee
SLIDE 9
Role of the Medication Safety Pharmacist
Assist in development and review of
medication-use policies
Monitor compliance with standards set
forth by JCAHO
National Patient Safety Goals
SLIDE 10
Patient Safety Initiatives
Sound-alike/ Look-alike medications Dangerous abbreviations Medication Reconciliation Medication Labeling Patient Identification Standardize and limit the number of drug
concentrations
SLIDE 11
Patient Safety Organizations
The Institute of Safe Medication Practices
http://www.ismp.org
JCAHO
http://www.jointcommission.org
Institute of Medicine
http://www.iom.edu
Institute for Healthcare Improvement
http://www.ihi.org/ihi
Agency for Healthcare Research and Quality
http://www.ahrq.gov
SLIDE 12
Safe Medication Management Fellowship
Offered by ISMP 12 month program Huntingdon Valley, PA Qualifications
Healthcare professional ≥1 year postgraduate clinical experience
SLIDE 13
Education
Pre-pharmacy at the University of Illinois Pharmacy school at the University of
Illinois
General Practice Residency at the
University of Washington
SLIDE 14
Work History
Pharmacy technician at Walgreens and
Evanston Northwestern Hospital
General pharmacy practice resident at
UWMC
General Surgery Clinical Pharmacist at
UWMC
Medication Safety Pharmacist
SLIDE 15