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Medication Error & Near Miss Reporting
Basic Medication Safety (BMS) Certification Course
King Saud bin Abdulaziz University for Health Sciences
Ministry of National Guard – Health Affairs
Learning Objectives
• Explain the reasons for reporting medication safety incidents
• State the types of reportable medication safety incidents
• Submit relevant information when reporting medication safety incidents
• Recall the local medication errors / near misses data
• Explain the mistake lesson learning cycle
Why Report?
• Ethical / medico-legal obligation
• Help identify hazards and risks in the system
• Sharing and learning REPORTS
What to Report?
Medication Safety
Incident
Potential Adverse Drug Event (PADE)
Near Miss Hazardous Condition
Adverse Drug Event
(ADE)
Adverse Drug Reaction
(ADR)
Medication Error
Source: AMNCH Tallaght: Medication Safety Incident Reporting Policy DTC4/2002
What Information to Report?
• JUST THE FACTS - include a factual description of what happened, how it happened, why it happened and the patient outcome
• Include names of products if the event involves a problem with labeling or packaging
• Include any additional patient monitoring or testing performed or medications administered as a result of the event
How to Report?
How to Report?
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What Happens to the Report?
What Happens to Me?
MNG-HA adopts a “JUST CULTURE” approach in error reporting:
• Creating an open, fair, and just culture
• Creating a learning culture
• Designing safe systems
• Managing behavioral choices
81
112
112
129
106
82
100
73
89
91
112
140
218
205
258
217
262
179
146
175
187
126
188
249
199
240
206
264
266
282
182
185
88
216
277
0
50
100
150
200
250
300
Cefuroxime allergy incident
Pharmacy Allergy Awareness Campaign
SRS campaign/ Good Catch
Program Ramadan
& Summer Holiday
Hajj Holiday
SRS Campaign/Reporting
Harm
MSP Allergy Awareness Campaign
MERS-CoV Outbreak
Number of Medication Error at KAMC - Riyadh from Jan 2013 – Nov 2015
86
409
863
493
133
22 2
71
0
100
200
300
400
500
600
700
800
900
1000
N/S A-Potential tocause
Harm/Damage
B-Near Miss-Errordid not reach the
individual
C-Error reachedindividual-No
Harm/Damage
D-Requiredmonitoring to
confirm NoHarm/Damage
E-TemporaryHarm-Required
intervention
F-TemporaryHarm-Requiredhospitalization
Not Applicable
Medication Error and Near Miss: Harm Category
Total number = 2079
January – December 2014: Central Region
Error / Near Miss
Recognize Error / Near Miss
Report Error / Near Miss
Analyze Error / Near Miss
System-wide corrective /
preventive action
Monitoring of implementation
What Did We Learn from the Data?
Overall Lessons Learned