1. Dr. Su Mon Thwe

2. that occurs during the process of https://lh3.googleusercontent.com/proxy/m6x2qjVccVS59COVE2F41nlMCZx_0jBXH4tzShjhzoHqLatkWyom9fDVT-sNjyprFLNbYhuD3e9UalheBwFFcnnIlNJ-XVgT PrescribingDispensingAdministeringMonitoring 8/31/2020Dr. Su Mon Thwe 2

3. 8/31/2020Dr. Su Mon Thwe 3 https://cedcommerce.com/blog/wp-content/uploads/2019/04/giphy.gif

4. Stems from 5 “Rights” of medicine administration Causes of Medication Errors 8/31/2020Dr. Su Mon Thwe 4

5. https://buzzbinpadillaco.com/wp-content/uploads/2017/03/Medical-Error.jpg 8/31/2020Dr. Su Mon Thwe 5

6. Examples of Medication Errors https://thumbs.gfycat.com/SoftJoyousHorsefly-max-1mb.gif 8/31/2020Dr. Su Mon Thwe 6

7. Wrong Medicine Mistaken for another medicine of a similar name https://www.psqh.com//images/stories/julaug10/hydroxyzine&hydralazine.jpg Your doctor prescribed this Is that what you got 8/31/2020Dr. Su Mon Thwe 7

8. https://userscontent2.emaze.com/images/95f60939-537e-48d5-abb3-b177b4e22c01/149b2b00fd5ee1c7b85f9b5d6fdce713.jpg Examples of Look-alike medicines 8/31/2020Dr. Su Mon Thwe 8

9. https://s3.amazonaws.com/lowres.cartoonstock.com/medical-chemist-pharmacy-pharmacists-drugs-medicines-jmp061024_low.jpg 8/31/2020Dr. Su Mon Thwe9

10. Wrong Patient Failure to check person’s identity https://i.ya-webdesign.com/images/hospital-band-png-3.png https://static-content.4tellus.com/wp-content/uploads/2017/03/21135029/patient-identification.jpg 8/31/2020Dr. Su Mon Thwe 10

11. https://lh3.googleusercontent.com/Mx9kLFh8Ba5v9jtGhmqPItpkrrfzBWpgMOgCwwhDWasqJGc25vAkdBATuXKGPWiTa3Y Wrong Dose 8/31/2020Dr. Su Mon Thwe11

12. Wrong dose is ordered on the medication chart https://thumbs.dreamstime.com/b/vector-illustration-businesswoman-character-nurse-holding-tags-such-as-wrong-172094050.jpg 8/31/2020Dr. Su Mon Thwe12

13. Error in calculating the mass or volume https://webstockreview.net/images/calculator-clipart-animation-10.gif 8/31/2020Dr. Su Mon Thwe13

14. Right dose is ordered, but illegible writing https://avatars.mds.yandex.net/get-pdb/251121/ff3c4063-7d72-4547-a9d6-13924b5c31db/orig 8/31/2020Dr. Su Mon Thwe14

15. https://assets.change.org/photos/5/cr/by/nUcRbYxieZUOGIQ-800x450-noPad.jpg?1559148484 8/31/2020Dr. Su Mon Thwe15

16. https://s3.amazonaws.com/lowres.cartoonstock.com/medical-doctors-prescriptions-drugs-handwriting-medical_research-aton1568_low.jpg 8/31/2020Dr. Su Mon Thwe16

17. Wrong Dose https://sites.google.com/site/safetysquad2012/_/rsrc/1332951304488/cartoons/gtt_rate_cartoon_lrmz.jpg 8/31/2020Dr. Su Mon Thwe17

18. https://www.uspharmacist.com/CMSImagesContent/2008/1/0801ISMPFigure.jpg Haldol 0.5 mg was misinterpreted as 5 mg 8/31/2020Dr. Su Mon Thwe18

19. How to prevent decimal point error?.1 mg0.1 mg1.0 mg1 mg 8/31/2020Dr. Su Mon Thwe19

20. http://patientsafety.pa.gov/ADVISORIES/PublishingImages/200503_19_fig1.JPG 4 U4 units 8/31/2020Dr. Su Mon Thwe20

21. Wrong Route https://image.shutterstock.com/image-photo/syringe-medical-injection-hand-palm-260nw-319466393.jpg 8/31/2020Dr. Su Mon Thwe21

22. https://www.wikihow.com/images/5/54/Organize-Your-Medications-Step-13.jpg https://www.noonanlawma.com/wp-content/uploads/2017/12/Pharmacy-Medication-Errors-1024x683.jpg Wrong Time 8/31/2020Dr. Su Mon Thwe22

23. Failure to recognize contraindications Inappropriate drug prescriptions https://www.wolterskluwercdi.com/images/sections/alert.png https://i.pinimg.com/originals/ee/ed/6b/eeed6bbd0262e30e5bd6b91c4a54adb8.gif https://encrypted-tbn0.gstatic.com/images?q=tbn%3AANd9GcSOWoz7Mva4LT94Uh8x5oNGRdQZrH4IGZAfOA&usqp=CAU 8/31/2020Dr. Su Mon Thwe23

24. https://webstockreview.net/images/medication-clipart-drug-interaction-1.png Failure to obtain information about other drugs the patient is taking 8/31/2020Dr. Su Mon Thwe24

25. Patient’s non-compliance. Patient may share a medication with others for any of several reasons. They think it is no longer needed because the bottle is empty or symptomatic improvement Inadequate communication between patient, prescriber & pharmacist Patients may not afford the prescribed medication. Fail to obtain medication Fail to take medication as prescribed Take medicine inappropriately Prematurely discontinue medication 8/31/2020Dr. Su Mon Thwe25

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27. The “Swiss-cheese” Model of medication error Check Erickson MA and Penning TM (2018). Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 13 th Edition https://i.pinimg.com/originals/db/a8/6e/dba86ebe7a14bca15347f1e122da1057.gif 8/31/2020Dr. Su Mon Thwe 27

28. Checking Procedure for Medicine Administration Right MedicinePersonDoseRouteTime Check 8/31/2020Dr. Su Mon Thwe28

29. Drug person’s diagnosis past health history (e.g., known drug allergies) ? appropriate for https://blog.commlabindia.com/wp-content/uploads/2015/01/converting-on-the-job-training-assessments-to-online-featured.gif 8/31/2020Dr. Su Mon Thwe29

30. https://blog.commlabindia.com/wp-content/uploads/2015/01/converting-on-the-job-training-assessments-to-online-featured.gif Are you aware of ? drug’s action adverse effects contraindications normal dose range drug interactions 8/31/2020Dr. Su Mon Thwe30

31. https://blog.commlabindia.com/wp-content/uploads/2015/01/converting-on-the-job-training-assessments-to-online-featured.gif Is the correct form of medication used (eg. tablet, injection)? Calculate the amount of medication required? Recheck the calculation. Calculate the amount of medication required? Recheck the calculation. Is the dose appropriate for the person’s age & size? Is Right time for medication to be given? 8/31/2020Dr. Su Mon Thwe31

32. https://image.shutterstock.com/image-photo/pharmacist-reading-doctor-prescription-drugstore-260nw-1407136556.jpg https://s3.amazonaws.com/lowres.cartoonstock.com/education-teaching-school-excuse-doctors_note-doctor_s_note-homework- cwln706_low.jpg Is prescription writing clear? 8/31/2020Dr. Su Mon Thwe 32

33. Check the label of the container following removal from drug trolley prior to removal of medication before returning it to drug trolley https://lh3.googleusercontent.com/proxy/fE60W9sptUxo5JMyUFRK-6xfu1OYfIoxc7AXsaSSUvsnFNOgsEE4oIgboVwc73efZozG- A_aHjPndHborPnJQtZVn8vOgpU4oA https://www.picturesof.net/_images_300/Pharmacist_Reading_the_Label_on_a_Bottle_Medication_Royalty_Free_Clipart_Picture_090213- 031815-876042.jpg http://images.clipartpanda.com/pharmacy-clipart-0511-1201-0317-3734_pharmacist_preparing_prescription_medication__clipart_image.jpg Does the label matched up with the drug order? 8/31/2020Dr. Su Mon Thwe33

34. https://www.zebra.com/content/dam/zebra_new_ia/en-us/solutions-verticals/vertical-solutions/healthcare/photography- website/healthcare-photography-website-identity-management-800x450.jpg Check the person’s identity label against the drug order. Check the person’s full name and the unit record number. Check the person’s identity label against the drug order. Check the person’s full name and the unit record number. 8/31/2020Dr. Su Mon Thwe 34

35. https://thumbs.dreamstime.com/z/close-up-doctor-medicines-clipboard-medicine-healthcare-people-concept-drugs- showing-jar-medication-105710072.jpg Document the drug order following administration. 8/31/2020Dr. Su Mon Thwe 35

36. https://content.presentermedia.com/files/clipart/00014000/14981/doctor_taking_notes_from_patient_300_wm.jpg Observe for therapeutic effects, adverse effects & allergies. 8/31/2020Dr. Su Mon Thwe 36

37. Take Home Message Medication errors are preventable Failure to follow the “5 Rights” of medicine administration leads to Medication errors. By using a systematic approach to medicine management: several checkpoints in each and every step of prescription, dispensing, administration & monitoring could largely avoid medication errors. 8/31/2020Dr. Su Mon Thwe 37

38. References Bullock. S & Manias. E. (2014). Chapter 10: Medication Errors, In: Fundamentals of Pharmacology, 7 th Edition, Pearson, Australia. Pp. 92-95. Erickson. M.A. & Penning. T.M. (2018). Chapter 4: Drug Toxicity and Poisoning, In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, Ed: Brunton. L.L., Hilal-Dandan R and Knollmann. B.C., 13 th Edition, USA, The McGraw-Hill Companies Inc. pp. 61. Lofholm. P.W. & Katzung. B.G. (2018). Chapter 65: Rational Prescribing & Prescription Writing, In: Basic & Clinical Pharmacology, Ed: Katzung. B.G., 14 th Edition; USA, The McGraw-Hill Companies Inc., Lange Medical Publications. pp. 1146-1155. 8/31/2020Dr. Su Mon Thwe 38

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