Where do medication errors occur? - Prior to automation of pharmacy systems.
39% prescribing errors
12% transcribing errors
11% dispensing errors
38% administering errors
Swiss Cheese Model of Accident Causation - used in risk analysis of human systems in healthcare
each step of process has potential failure
an error may allow a problem through, but each layer defends against potential for error to impact
outcome
Catastrophic error = when all holes align and defenses are defeated
Drug prescribing process - Front-end loaded with safeguards
Nurse and pharmacist reviews order, nurse administering reviews before given to patient
electronic medication ordering - Simplifies ordering process, eliminates unnecessary steps, and reduces
size/quantity of "holes"
Provider has clinical support tools to help write order (Patient allergy alert)
Pharmacist has clinical support tools (DDI alerts, drug allergy alert)
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