Course Description

Medication errors are preventable events that can happen in clinics, hospitals, pharmacies, and patient’s homes. Patients and healthcare providers can work together to help avoid errors from occurring and should report all events to prevent future systematic mistakes from happening again. This course will introduce healthcare workers to the role of regulation, culture, systems, and technology in maintaining medication and patient safety. Attendees will learn how to prevent, detect, and report medication error events.

Course Outline

Hour #1

Introduction to patient safety

• What are adverse drug events?
• What are medication errors?
• Factors contributing to medication errors
  • Human-related errors
  • System-related errors
  • Medication-related errors
• Root Cause Analysis
  • What is Root Cause Analysis
  • Swish Cheese Model
  • Fishbone Diagram

Hour #2

• Ways to prevent medication error
  • Five-Rights
  • Patient safety communication strategies
  • Medical abbreviation
  • Look-alike, sound-alike drugs
  • High alert and high-risk medications
  • Health literacy in patient safety
  • Culture of Safety

Proper medication disposal

• Organizations that Promote Safe Standards of Care
  • Agency for Healthcare Research and Quality (AHRQ)
  • The Food and Drug Administration (FDA) MedWatch
  • Institute for Safe Medication Practices (ISMP)
  • The Joint Commission (TJC) Standards
  • National Patient Safety Goals (NPSG)
• Medication error reporting systems
  • Voluntary vs. mandatory medication error reporting
  • Adverse event reporting
  • Disclosure

Identifying medication errors case