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PRESENTATIONPRESENTATION

OFOFADR & MEDICATIONADR & MEDICATION

ERRORERRORFROMFROM

OCTO09 TO FEB10OCTO09 TO FEB10

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OC O 09 O 0OC O 09 O 0

AGENDAAGENDA

Discussion about previous MOMDiscussion about previous MOM

ADRADR

Medication ErrorMedication Error Summary of Medicine audit committeeSummary of Medicine audit committee

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ADVERSE DRUG REACTION

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Graphical Data of ADRGraphical Data of ADR

month

number

00 .5

11 .5

22 .5

33 .5

OCTO

MBER

NOVE

MBER

DECE

MBER

JANU

ARY

FEBR

UARY

S er i e s

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ADR DATAADR DATA

MONTH ADR

OCTOBER 03

NOVEMBER 00

DECEMBER 00

JANUARY 01

FEBRUARY 00

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ADR DATA FROM OCT09ADR DATA FROM OCT09

DATE&

DEPT

ADR TYPEBT

REACTION

SYMPTOM ACTION

9/10/09

Cathlab

Omnipaque

Dye related

[moderate]

Pt having rigor afterangiography

Inj avil 1 amp iv statgiven & inj effcorlin 1vial given

9/10/09

Cathlab

Omnipaque

Dye related

[moderate]

Pt having rigor afterangiography

Inj avil 1 amp iv statgiven & inj effcorlin 1vial given

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ADR DATA FROM Jan10ADR DATA FROM Jan10SR

NO

DATE &

DEPT

ADR TYPE

BT REACTION

SYMPTOM ACTION

1 05.01.10MICU

Inj PCV related Rashes & bloodspots on viggo site

Inj.Avil &Inj.Effcorlin given

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MEDICATION ERROR

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Graphical Data of MEsGraphical Data of MEs

1

58 7

14

4

12

02468

101214

march april may june july aug sep

month

number

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MONTH OF OCTO09MONTH OF OCTO09

PRESCRIPTION ERROR 01

TRANSCRIPTION

ERROR

00

REQUISITION ERROR 00

DISPENSATION ERROR 05

ADMINIATRATIONERROR

02

TOTAL MEs 08

t &D t T f E D t il C ti ti t k

http://../Local%20Settings/Temporary%20Internet%20Files/Content.IE5/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/UME81V1L/ppt%20P&T.ppthttp://../Local%20Settings/Temporary%20Internet%20Files/Content.IE5/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/UME81V1L/ppt%20P&T.ppthttp://../Local%20Settings/Temporary%20Internet%20Files/Content.IE5/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/UME81V1L/ppt%20P&T.ppt

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te &Dept Type of Error Details Corrective action taken

/09

floor

Dispensation error Inj Taravid was Dispensed in steadof tab. Taravid

Informed to store person Nima &correction has been done

/09

floor

Dispensation error Syp. Codein issued in stead of tab.Codein

Informed to store person

[ mr.jignesh ] & correction hasbeen done

0/09

ward

Administration error Delay medication given due to delay

viggo insertion by paediatrician

Inform to consultant &

immediately medicine given afterviggo insertion

0/09

ward

Prescription error Inj thyrocortisone has been written instead of hydrocortisone

After noticed this immediatelycorrection has been done

0/09

floor

Dispensation error Tab Dytor plus 10 mg issued in steadof 5mg

Informed to store person[ Mr.Himanshu ] & correction hasbeen done

0/09

floor

Administration error Cap. Flucan

[ 2oomg] given in stead of 4oomg

Informed to consultant &

immediately remaining dose hasbeen given B/O him , explanation

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MONTH OF NOVE09MONTH OF NOVE09

PRESCRIPTION ERROR 00

TRANSCRIPTION ERROR 04

REQUISITION ERROR 00

DISPENSATION ERROR 03

ADMINIATRATION ERROR 03

TOTAL MEs 10

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Date &Dept Type of Error Details Corrective action

taken

09.11.09

4th floor

Transcription Error Inj.N.S 0.45%200ml/hrs wasprescribed by consultant butin treatment sheet M.O haswritten 100ml/hr

Next day consultantcame for the round thattime he has seen thetreatment sheet

10.11.09

4th floor

Transcription error&administration Error

In cross reference consultanthas written anti hypertensivemedicine before ot but dr.Written w/h in treatmentsheet.

10.11.09

MICU

Dispensation Error Inj.Gatiquine request sent bysister but from pharmacy theysent used injection.

Injection return to thepharmacy dept.

11.11.09RTU Transcription error Tab.syscan 150mg prescribedby consultant buttranscription is tab.syscan50mg in treatment sheet

Staff is aver about doseof medicine so rightdose given to patient

13.11.094th floor

Administration error Missing routine dose of tabtridomet

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Cont.Cont.

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MONTH OF DECE09MONTH OF DECE09

PRESCRIPTION ERROR 00

TRANSCRIPTION ERROR 00

REQUISITION ERROR 00

DISPENSATION ERROR 01

ADMINIATRATION ERROR03

TOTAL MEs 04

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Date &Dept Type of Error Details Corrective actiontaken

8.12.09

MICU

Dispensation Error

Inj.Mgso4 50%& issued fromstoreInj.Mgso4 25%

Immediatemedicinereturned &correctiondone.

21.12.09

PWARD

Administration error

Tab.Frisiumprescribed at2:00pm but

order follow till10:00pm

Traininggiven tostaff

31.12.09

4th floor

Administrat

ion Error

Doctor ordered

Tab.Revotril0.5mg at 10pm

Training

given to thestaff

CC t

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Cont.Cont.

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MONTH OF JAN10MONTH OF JAN10

PRESCRIPTION ERROR 00

TRANSCRIPTION ERROR 00

REQUISITION ERROR 00

DISPENSATION ERROR 00

ADMINIATRATION ERROR 03

TOTAL MEs 03

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Date &Dept Type of Error Details Corrective actiontaken

10.01.103rd floor

Administration

error

Inj clexoneadministrated at9:00am insteadof 9:00pm

Changetiming fornext doseas per

consultantadvise

11.01.10

4th floor

Administration

error

Tab vizyladministrated to

wrong patient

Staff wasterminated

25.01.10

4th floor

Administra

tion

Wrong drug

administrated to

Inform to

consultant

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Cont.Cont.

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MONTH OF FEB10MONTH OF FEB10

PRESCRIPTION ERROR 00

TRANSCRIPTION ERROR 01

REQUISITION ERROR 00

DISPENSATION ERROR 02

ADMINIATRATION ERROR 03

TOTAL MEs 06

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Date &Dept Type of Error Details Corrective actiontaken

04.02.10

3rd floor

Administration error

Tab.eltroxin notgiven

Informed toconsultantand made

staff to readwrite

medicineadministration policy.

07.02.10

4th floor

Administration error

Inj.5% dextrosegiven instead of

3% NS

Inform toconsultant

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20.02.10

3rd floor

Transcripti

on Error

Wrong dose

transcribed bymedical officer

Due to that

administration erroralso happen

20.02.10

3rd floor

Dispensation &

Administration error

Tab.mesacolod(1200)

prescribed byconsultant butdispensed &administeredtab.mesacol 400

Inform tostore &change.

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MONTH OF AUG09MONTH OF AUG09

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Date &Dept Type of Error Details Corrective actiontaken

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MONTH OF SEP09MONTH OF SEP09

Date &Dept Type of Error Details Corrective action

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Date &Dept Type of Error Details Corrective actiontaken

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ummary o e c ne au comm eeummary o e c ne au comm ee

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ummary o e c ne au comm eeummary o e c ne au comm ee(Needs Committee members opinions for(Needs Committee members opinions for

improvement )improvement )

To make availability of certain common medicines atTo make availability of certain common medicines atcentral level / nursing stationcentral level / nursing station

To use cheaper medicines but not comprising qualityTo use cheaper medicines but not comprising qualitymaterial. Eg. Dressing materials, Baxter, dynaporematerial. Eg. Dressing materials, Baxter, dynapore

Material which can be reused can be used afterMaterial which can be reused can be used afterautoclave instead of disposableautoclave instead of disposable Smaller quantity of medicines should be given insteadSmaller quantity of medicines should be given instead

of higher quantityof higher quantity Costly medicines should be given loose or should beCostly medicines should be given loose or should be

taken backtaken back Costly medicines should be given at Market rateCostly medicines should be given at Market rate Alternative brand should allowed to be usedAlternative brand should allowed to be used

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ContCont

Medicine restriction should be at nursing level beforeMedicine restriction should be at nursing level before

indentingindenting

Counter sign by CMA should be there to keepCounter sign by CMA should be there to keep

restrictionrestriction All Medicines list should be counter signed by patientsAll Medicines list should be counter signed by patients

relativesrelatives

Staff training for wastage of material or pilferage ofStaff training for wastage of material or pilferage of

medicinesmedicines

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