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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
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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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