Pharmacist: Thorya Al-zahrany Member In National Drug Information Center supervisor of medication patient education at pharmacy care administration at Medina Region

1. Pharmacist: Thorya Al-zahrany
Member In National Drug Information Center
supervisor of medication patient education at pharmacy care
administration at Medina Region

2. Presentation titles and details
First presentation
Introduction the importance of medication safety
implantation
• Second presentation
Most common causal factors which contribute to
medication errors during prescribing stage
• Third presentation
Medication safety terminology, strategies to reduce
Medication error, and reporting system

3. The Extent of the Medications
Error Problem
• 1. INTRODUCTION
• The matter of medical errors is not a new
topic and it did not become a widespread
subject until the last decade. Statistics show
the medical field has improved greatly since
IOM’s report in 1999; However, those error
ratios can still be improved upon or even
eliminated completely.

4. The Extent of the Medications Error problem
‫الدوائية‬ ‫األخطاء‬ ‫مشكلة‬ ‫حجم‬
In the Institution of Medicine (IOM) report, To Err is a Human:
‫األحزاب‬ ‫سورة‬ ‫في‬ ‫يقول‬ ‫وجل‬ ‫عز‬ ‫هللا‬:َ‫ع‬ َ‫ة‬َ‫ن‬‫ا‬َ‫م‬َ ْ‫األ‬ ‫َا‬‫ن‬ْ‫ض‬َ‫ر‬َ‫ع‬ ‫ا‬َّ‫ن‬ِ‫إ‬ ﴿ِ‫ض‬ ْ‫ر‬َ ْ‫األ‬ َ‫و‬ ِ‫ت‬‫ا‬ َ‫او‬َ‫م‬َّ‫س‬‫ال‬ ‫ى‬َ‫ل‬
ْ‫ن‬َ‫أ‬ َ‫ْن‬‫ي‬َ‫ب‬َ‫أ‬َ‫ف‬ ِ‫ل‬‫ا‬َ‫ب‬ ِ‫ج‬ْ‫ال‬ َ‫و‬ِ ْ‫ال‬ ‫ا‬َ‫ه‬َ‫ل‬َ‫م‬َ‫ح‬ َ‫و‬ ‫ا‬َ‫ه‬ْ‫ن‬ِ‫م‬ َ‫ن‬ْ‫ق‬َ‫ف‬ْ‫ش‬َ‫أ‬ َ‫و‬ ‫ا‬َ‫ه‬َ‫ن‬ْ‫ل‬ِ‫م‬ْ‫ح‬َ‫ي‬‫وما‬ِ‫ل‬َُ َ‫ان‬َ‫ك‬ ِ‫ك‬َّ‫ن‬ِ‫إ‬ ِ‫ان‬َ‫س‬ْ‫ن‬َ‫ج‬﴾ ‫وال‬ِ‫ه‬
• ‫و‬ ‫الصالة‬ ‫عليك‬ ‫وقال‬‫السالم‬(:(ِ‫وخير‬ ٌ‫ء‬‫ا‬َّ‫خط‬ َ‫آدم‬ ‫ني‬َ‫ب‬ ُّ‫ل‬ِ‫ك‬َ‫ائين‬َّ‫َط‬‫خ‬‫ال‬َ‫وابون‬َّ‫ت‬‫ال‬))
• [‫مالك‬ ‫بن‬ ‫أنس‬ ‫عن‬ ‫الترمذي‬ ‫أخرجك‬]
.
4

5. Error Occurrence
‫حدوث‬‫الخطأ‬
• Most error are committed by hardworking,
well trained individuals 5
Errors are not surprising
given the fact that human
beings by their very nature
make errors.
‫حالة‬‫األنسان‬‫األصلية‬

6. The Extent of the Medications Error
problem
Building a Safer Health System, estimates that:
 44,000 to 98,000 Americans die each year from medical
error, with an associated cost of$17 to $29 billion.
 More than 7,000 American die each year from medication
error.
 Those numbers as high and unacceptable as they seem may
still be an underestimate

7. Burden of the Medical Errors
• The Institute of Medicine’s (IOM) estimated as
many as 98,000 people die every year at a cost of
$29 billion.
• (2004) Health Grades report stated that annual
deaths attributable to medical errors may be as
high as 195,000 deaths.
• This number compared to other causes of death
is exceeded only by heart disease (700,142) and
cancer (553,768).
• 1 out of 5 injuries or deaths from errors
associated with Adverse Drug Events are
preventable. (Pronovost)
1 To Err Is Human: Building a Safer Health System, Institute of Medicine, 1999
2 Deaths/Mortality, 2005, National Center for Health Care Statistics at the Centers for Disease Control, viewed at
http://www.cdc.gov/nchs/fastats/deaths.htm.

8. • Approximately 5% of all patients admitted to
the hospitals experienced a medication error
during their hospital stay.
• Based on the number of medication errors,
one medication error occurs approximately
every 23 hours.
1 medication error /23hr.
The Extent of the Medications Error
problem (cont.)
8
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9. • 25 Medication errors that resulted in adverse patient
outcomes occurs in 10,000 of admitted patients.
• A medication-related adverse outcome occurs every 19
days.
The Extent of the Medications Error
problem (cont.)
9
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11. Medication errors occurring in hospitals have become a worldwide concern for
healthcare policy makers, professionals and the public.
These errors harm at least 1.5 million United States residents annually, and
treating injuries caused by these errors cost at least 3.5 billion dollars (Aspden
et al., 2006).
In one U.S. study in two academic hospitals, the incidence of adverse drug
events (ADEs) for hospitalized patients was estimated to be 6.5 per hundred
admissions (Bates et al., 1995).
A more recent study in community hospitals found an even higher rate of ADEs
of 15 per hundred admissions (Hug et al., 2010).
In Australia, up to 4% of all hospital admissions are medication-related
(Runciman et al., 2003).
In Saudi Arabia, two recent studies estimated that the prevalence of
prescribing errors in hospital inpatient ranges between 13 and 56 per 100
medication orders (Al-Dhawailie, 2011; Al-Jeraisy and M., 2011). These data
suggest that medication safety is an important international contributor to
morbidity and costs of healthcare.
Facts

12. 12

20. Impact‫اثر‬ of Medication Errors
• Loss of confidence
• Psychological impact
• ‫قانوني‬ ‫مسئولية‬ Liability issues
• Cost
• Death
The Extent of the Medications Error problem
(cont.)
‫الدوائية‬ ‫األخطاء‬ ‫مشكلة‬ ‫حجم‬(‫تابع‬)
20
3

22. Medication Errors Cost
‫الدوائية‬ ‫األخطاء‬ ‫تكلفة‬
Medication errors are bad business because they
are costly in both human and financial terms.
22

23. • 2 serious medication errors that caused patient harm
occurs with every 100 admissions.
• An average of 4.6 days were added to these patients’
lengths of stay.
• In a 700-bed teaching hospital, the extrapolated cost of
preventable adverse drug events over the course of a
year was $2.8 million dollars.
Medication Errors Cost (cont.)
‫األخطاء‬ ‫تكلفة‬‫الدوائية‬(‫تابع‬)
23
1

24. • An extra $5,857 per event was
added to these patients’ costs.
• Additional Care
• Loss of income for patient, / their
caregivers.
Medication Errors Cost (cont.)
‫الدوائية‬ ‫األخطاء‬ ‫تكلفة‬(‫تابع‬)
24
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26. HOW WE CAN ELIMNATIG MEDICAL
ERROR??????

27. Patient Safety Goals

28. Patient Safety Definition
• Healthcare organizations including
hospitals were founded to give care to
those who need it and to keep
patients safe.
• It is generally agreed upon that the
definition of patient safety is…

29. National Safety Goals
• Improve the accuracy of patient
identification.
• Improve the effectiveness of
communication among caregivers.
• Improve the safety of using medications.

30. National Safety Goals
• Reduce the risk of healthcare associated
infections.
• Accurately and completely reconcile
medications across the continuum ‫سلسلة‬
‫متصلة‬of care.
• Reduce the risk of patient harm resulting
from falls.