Case Of Medication Error
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Medication Error Definition
Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Cases & Commentaries Published May 2013 Right medication error statistics Regimen, Wrong Cancer: Patient Catches Medical Error Spotlight Case Commentary by Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD Sections Case Objectives Case & Commentary: Part 1 Case & Commentray: http://www.medscape.com/viewarticle/490499 Part 2 References Table Figure Topics Resource Type Cases & Commentaries Approach to Improving Safety Error Analysis Safety Target Ordering/Prescribing Errors Chemotherapeutic Agents Setting of Care Hospitals Clinical Area Medical Oncology Target Audience Health Care Providers Quality and Safety Professionals Error Types Epidemiology of Errors and Adverse Events Near Miss More PPT PowerPoint Presentation (766 K) Download free PowerPoint viewer Share Facebook Twitter Linkedin Email Print Case https://psnet.ahrq.gov/webmm/case/299/right-regimen-wrong-cancer-patient-catches-medical-error Objectives Appreciate that chemotherapy administration is hazardous and challenging. Describe the most common types of errors associated with chemotherapy administration. State why errors may be common when chemotherapy is administered in the inpatient setting. Describe the importance of understanding the process of chemotherapy administration and the importance of standardizing the process. Case & Commentary—Part 1 A 48-year-old man with a history of metastatic penile cancer was admitted to an inpatient internal medicine service for his fourth round of chemotherapy. He had three previous uncomplicated admissions where he received a standard protocol of 3 days of paclitaxel, ifosfamide, and cisplatin. The patient received this regimen for 3 days with minimal adverse effects. On hospital day 4, based on his previous admissions for chemotherapy, the patient was expecting to go home. In the morning his bedside nurse for the day came in and stated that she would be giving him his fourth day of chemotherapy. The patient was surprised by this and, before the chemotherapy was administered, asked to speak with the oncology team who was directing his care. After speaking with the patient, the oncology fellow examined the orders in more detail and realized that the incorrect chemot
TopicsAll TopicsAtrial FibrillationCardiovascular DiseasesCOPDMen's HealthDiabetes Type 2PainHIV AIDSNervous System DiseasesObesityRespiratory Diseases MAIN MENU Home Topics Dermatology Cardiovascular Diabetes GI HIV/AIDS Conferences Quizzes Photoclinic Image IQ Pediatrics Welcome Guest | Login or Register Welcome My Account|My Account or Logout Connect http://www.consultantlive.com/nervous-system-diseases/medication-errors-adults%E2%80%94case-1-warfarin to other sites within the UBM Medica Network Search form Search ConsultantLiveAll Sites Topics:Atrial Fibrillation|Cardiovascular Diseases|COPD|Men's Health|Diabetes Type 2|Pain|HIV AIDS|Nervous System Diseases|Obesity|Respiratory Diseases|Browse All TopicsAll TopicsAtrial FibrillationCardiovascular DiseasesCOPDMen's HealthDiabetes Type 2PainHIV AIDSNervous System DiseasesObesityRespiratory Diseases ubmslateCL-logo-ubm ≡ Main menuHomeTopicsBuyer's GuideJournal MAIN MENU Home Topics Dermatology Cardiovascular Diabetes GI HIV/AIDS Conferences Quizzes Photoclinic Image IQ Pediatrics Medication Errors in medication error Adults—Case #1: Warfarin Medication Errors in Adults—Case #1: Warfarin July 29, 2013 | Nervous System Diseases, Atrial Fibrillation, InfectionBy Bradley M. Wright, PharmD, BCPS Medication errors may occur at any point in the health care system. Obtaining a true estimate of the number of errors is difficult, but preventable medication errors are known to increase patient harm and total case of medication health care costs.1 This series will highlight some of the most important errors and address methods to decrease the risk of them occurring. Drug #1: WarfarinA 52-year-old male taking warfarin daily for prevention of stroke with atrial fibrillation develops a skin infection and visits the local urgent care center on a weekend for evaluation and treatment. The patient receives a diagnosis of cellulitis and a prescription for Bactrim®, trimethoprim/sulfamethoxazole (TMP/SMX), to be taken twice daily. The drug is dispensed by a pharmacy near the urgent care center, not the patient’s usual pharmacy. Several days later, the patient is admitted to the hospital with an acute bleed and an elevated international normalized ratio (INR).What is the problem in this scenario?DiscussionWarfarin remains one of the most frequently prescribed medications in the United States, and it appears on the Institute for Safe Medication Practices list of high-alert medications because overanticoagulation or underanticoagulation has important consequences.2 In addition, medication errors that lead to adverse drug events may be more common with warfarin because it has a large number o