...filling errors. Medication errors are a leading cause of mortality in the United States (Kohn, Corrigan, and Donaldson, 2000). Dispensing errors account for ~21% of all medication errors (Santell, Hicks, McMeekin, and Cousins, 2003). In addition to causing serious morbidity and mortality, dispensing errors increase the economic burden on society by adding to health care costs. The prescription filling process map: Prescription filling refers to...
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...Patient safety is defined as ‘the prevention of harm to patients, including through errors of commission and omission’. The role of pharmacists has been clinically proven to improve many outcomes regarding patient health, including greater patient safety, improved disease and drug therapy management, effective healthcare spending, improved adherence and improved quality of life (Canadian Pharmacists Association, 2008). The focus on patient care stemmed from a 1999 US report by the institute of Medicine titled, ‘To Err is Human: Building a safer Health System’. This report detailed the costs of medical errors to the US economy and how medical errors numbered higher than deaths due to AIDS, motor vehicle accidents, and breast cancer, combined. The report went on to descried how errors can be reduced (Institute of Medicine,1999). For centuries, pharmacists have been the guardians/safeguards against "poisons" those substances which could cause harm to the public. Now more than ever pharmacists are charged with the responsibility to ensure that when a patient receives a medicine, it will not cause harm. As highlighted in a report produced in November 2009 "Pharmacy Intervention in the Medication-use Process - the role of pharmacists in improving patient safety", the involvement of pharmacists in patient safety can be as early at the prescribing phase and up to the administration of the medicines. In many cases, pharmacists are supported by programmes and activities from their national...
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...Medication errors are a very serious patient safety problem. They can be described as any mistake or incorrect judgement of a prescription, in dispensing or administering medication. It can be the mistake of a doctor, nurse or pharmacist. In the USA the Institute of medicine reported that 44,000 to 98,000 deaths were caused by medical errors yearly. 7,000 of them due to medication errors. In addition, Johnson and Bootman calculated 116 million visits to doctors, 17 million visit to Emergency Department, 8 million hospital admissions and 3 million long-term care admissions per year due to medication errors (Kwabena 2004). There are three people involved in medicine. The doctor who orders the medicine, the pharmacist who supplies the medicine and the nurse who gives the medicine. Any mistakes in their roles will result in medication errors. Thus, there are...
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...Medication Dispensing Errors and Potential Adverse Drug Events before and after Implementing Bar Code Technology in the Pharmacy Eric G. Poon, MD, MPH; Jennifer L. Cina, PharmD; William Churchill, MS; Nirali Patel, PharmD; Erica Featherstone, BS; Jeffrey M. Rothschild, MD, MPH; Carol A. Keohane, BSN, RN; Anthony D. Whittemore, MD; David W. Bates, MD, MSc; and Tejal K. Gandhi, MD, MPH Background: Many dispensing errors made in hospital pharmacies can harm patients. Some hospitals are investing in bar code technology to reduce these errors, but data about its efficacy are limited. Objective: To evaluate whether implementation of bar code technology reduced dispensing errors and potential adverse drug events (ADEs). Design: Before-and-after study using direct observations. Setting: Hospital pharmacy at a 735-bed tertiary care academic medical center. Intervention: A bar code–assisted dispensing system was implemented in 3 configurations. In 2 configurations, all doses were scanned once during the dispensing process. In the third configuration, only 1 dose was scanned if several doses of the same medication were being dispensed. Measurements: Target dispensing errors, defined as dispensing errors that bar code technology was designed to address, and target potential ADEs, defined as target dispensing errors that can harm patients. Results: In the pre– and post–bar code implementation periods, the authors observed 115 164 and 253 984 dispensed medication doses, respectively...
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...Statistical Thinking in Health Care Case Study 1 Week 4 Mat 510- Business Statistics November 1, 2015 With information from the case we will attempt to address some explanations to the issue of medication errors being dispensed at HMO pharmacy. A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality shows the categories of dispensing errors. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the pharmacist, this list can be extended by the addition of three other categories: failure to detect and correct a prescribing error before dispensing; failure to detect a manufacturing error before dispensing; and failure to provide adequate patient counseling in order to prevent administration errors. These categories arise in other segments of the pharmaceutical patient care chain, but they are nevertheless important when one strives for a full assessment of the pharmacy's performance. (a-Chun Cheung, Marcel L Bouvy, and Peter A G M De Smet) I am going to attempt a process map to the best of my ability on filling process for HMO’s pharmacy, in which some key problems that the HMO’s pharmacy might be experiencing. A SIPOC diagram is a tool used by a team to identify...
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...Statistical Thinking in Health Care Case Study 1 Week 4 By Shirley Davis Dr. Sally Robison Mat 510- Business Statistics November 1, 2015 With information from the case we will attempt to address some explanations to the issue of medication errors being dispensed at HMO pharmacy. A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality shows the categories of dispensing errors. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the pharmacist, this list can be extended by the addition of three other categories: failure to detect and correct a prescribing error before dispensing; failure to detect a manufacturing error before dispensing; and failure to provide adequate patient counseling in order to prevent administration errors. These categories arise in other segments of the pharmaceutical patient care chain, but they are nevertheless important when one strives for a full assessment of the pharmacy's performance. (a-Chun Cheung, Marcel L Bouvy, and Peter A G M De Smet) I am going to attempt a process map to the best of my ability on filling process for HMO’s pharmacy, in which some key problems that the HMO’s pharmacy might be experiencing. A SIPOC diagram...
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...Right time. Management Criteria: The criterion set by management is implementing the system which improves the problems existing in the current system and achieves its goals with the least possible cost due to the cut in funds by the Government. Analysis: There are many options that be considered to overcome the persisting issues. The first option is to introduce the Unit dose system. The unit dose system is a medication dispensing system which the doses are individually prepared and packaged for each individual patient in a bubble pack, which then labeled with the name of drug, patient, dose and the time the medication needs to be given, each bubble has the medication for five days. The main goal is to reduce the errors in medications and medication waste, nursing time involved in dispensing the medications to the patients and it will also reduce the inventory holding cost. The criteria would be to see if the system has reduced the errors and issues and how much cost does it saves and incur. Even though the option might help in reducing the errors and might save time that can be used somewhere else to treat more patients, but it isn’t cost effective and incur more cost than the bulk purchasing, and it requires more labor then in bulk purchasing which can be bought once and used for long period. Another option available is to apply the Bar-Code Medication and Administration system (BCMAS), this system has bar codes for each drug and for nurses and...
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...SCENARIO ANALYSIS According to the Medication Administration Process, there is a step missing from the scenario. The steps missing are Step 3, Step 4, Step 6, Step 7, Step 8, and Step 9. All these measures of accurate Medication Administration Process can be realized to be missing from the scenario due to what the nurse did or did not do, did right or wrong, at the right time or not. Some errors occurred during the Medication Administration Process in the scenario. The first error is that the unit clerk communicates the medication order to the nurse verbally while it should be written or typed. When a medication order is typed, it rarely leads to misunderstanding or errors. The second error is when the nurse takes medication from bin number...
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...has made slow progress in improving patient’s safety. The role of nursing in improving medication safety has been largely underestimated. Much of the research undertaken to date in relation to adverse medication events has neglected the impact that nurses have or could have in improving patient safety. In examining literature regarding adverse medication events one can see the urgent need for significant improvement in medication practices and processes. In addition that this health care issue will only improve with the participation of all disciplines working towards a common goal of improving the safety of those in our care. Introduction Medications play a key role in healthcare but can also be a significant key cause of medical error and of adverse patient outcomes. Nurses by the nature of their roles in medication administration can be the last line of defense in eliminating or reducing adverse medication events. The administration of medication is a common and almost routine activity in a nurse’s daily work, yet it is fraught with complexity and risk for both the patient and nurse. As a student nurse working in partnership with a registered nurse I have observed a variety of practices in medication administration that have varied from what I have been taught in class. On reflecting on these practices and questioning nurses why such practice has been adopted has illustrated to me both the flawed processes and environment that nurses provide care in. Nurses will need...
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...Medication Administration Introduction The medication administration process has a direct impact on the patient’s health and well-being. The evaluation of the medication administration workflow is crucial to ensure that the right procedure is utilized to offer quality care. The proper design of the process makes sure that there is provision of safe, efficient, prompt, and patient-centered care. Also, there is the elimination of cases of medication administration errors in hospitals through the appropriate workflow design. The application of technological elements in the process with proper integration serves to enhance...
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...Working in a healthcare environment Medical Assistants have various responsibilities to carry out while working in the field. One of the most important responsibilities for Medical Assistants is the proper knowledge and understanding of preparing and administering medications. There are three different systems of measurements that Medical Assistants must fully comprehend to ensure the proper dosage is being administered exactly as the physician has ordered in order to ensure the safety of all patients being treated. The first and most commonly used system of measurement is the Metric System, this system is based upon mass, volume, and length. The second system of measurement is Household Measures; this system is typically used by patients...
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...safety concerns. The fee for- service compensation systems has done exceedingly well in increasing revenue to hospitals resulting from additional technology-related charges levied on patients for each dose dispensed (Cohen, 2002). From the evidences adduced in this research, bar code technology seems to hold great promise for general improvements in medication safety and efficiency. Nevertheless, evidence so far is limited by the lack of hard indisputable facts obtained from direct observation. Another deficiency is the lack of concurrent control groups, which is further putting current the adoption of the system in limbo. Statement of the Business Scenario Healthcare professionals know that they are susceptible to reading or transcription errors as humans in the course of their careers. However, with...
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...html Errors that occur earlier in the medication process are more readily detected (~50% are prevented during the ordering stage) while very few (< 2%) are caught at the administration stage (bates et al., 1995). further, it has been noted that more than one third of medication errors occur at the latter stage (leape et al., 1995). because of the relatively high proportion of errors and the lack of success preventing them, error reduction strategies targeted at the administration stage High rates of preventable medication errors have been repeatedly reported in studies in the medical literature (Bates et al., 1995; Leape et al., 1995; Flynn et al., 2002; Kanjanarat et al., 2003). It is difficult, however, to cite a single number to define the extent of the medication error problem due to differences in institutions, study methodologies, error definitions, and other variables. On the high end of estimates, one study that compiled data from 36 institutions reported 19% (~1 in 5) of the medication doses studied over a 4-day period involved medication errors (Barker et al., 2002). These errors included wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). The number of these errors deemed potentially harmful adverse drug events (ADEs) was 7%. A comprehensive review of medication error studies cited in the Institute of Medicine (IOM) 2000 report on errors in the U.S. healthcare system suggests that preventable ADEs, i.e., harmful medication errors, occur...
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...Business Proposal Tina Davis ECO/561 Economics Draft Business Proposal In an effort to serve the CVS Pharmacy’s consumer base better, the need to offer a wider variety of prescription medication selections and options system-wide. In this proposal, assumptions about the elasticity of demand and the market structure for these medications and expanded services will be included. Additionally, how the expansion will increase revenues will be explained. Further, a rationale for determining the profit-maximizing quantity will be provided. Decisions will be made by using the concepts of marginal costs and marginal revenue to maximize profit. A mix of pricing and non-pricing strategies will be suggested. This proposal will also explore options of creating or increasing barriers to entry. Further, increased product differentiation will be discussed. Finally, other way to minimize costs will be explored. Market Structure and Elasticity of Demand CVS retail pharmacies operate in a monopolistic competition market structure. According to Investopedia (2012), the monopolistic competition is, “A type of competition within an industry where: 1. Firms produce similar yet not perfectly substitutable products. 2. Firms can enter the industry if the profits are attractive. 3. Firms are profit maximizers. 4. Firms have some market power, which means none are price takers. Firms in a monopolistic competition sell goods that have either actual or perceived non-price differences...
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...Technology in Medicine In APA STYLE Abstract Thousands of people die each year as a result of medication errors. Medication errors can be attributed to faults in both humans and medication use systems. Therefore, it is necessary to address resolutions to both of these predicaments. The anticoagulant heparin is amongst the most implicated medications. Thus, it has been documented in the top five high-alert medications. Two notable events that triggered recent interest in this topic are the heparin overdoses that occurred in California, associated with actor Dennis Quaid’s newborn twins, and those affecting neonates in an Indiana hospital. The Failure Mode Effect Analysis (FMEA) is a proactive approach to error prevention. Implementation of an FMEA system would serve as a crucial method that will help to recognize potential failures of a product or process before adverse events occur. FMEA can help identify where the use of technology can be implemented to facilitate the reduction of medication errors, especially pertaining to heparin as in this case. Studies have shown how technology, such as computerized heparin nomagram system (HepCare), smart pump infusion technology, computerized physician order entry (CPOE), and the bar coding system, can reduce medication errors. Expanding nationwide awareness of these methods should result in a significant decline of medication errors. Introduction ...
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