Best Practice of Risk Management in Medication Error 24 August … · 2019. 5. 7. · Type of...
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SMART NURSES…SMART CARE
Best Practice of Risk Management in Medication Error
24 August 2016
พว.อรศร อมสมบรณหวหนาหอผปวยวกฤตหวใจ
ศนยการแพทยสมเดจพระเทพรตนคณะแพทยศาสตรโรงพยาบาลรามาธบด
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Objectives
• Polices awareness to improve working areas and increase the quality practice required for medication administration
• Reducing harm from Medication Error
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2010 National Patient Safety Goals
Medication Safety Goal ( SIMPLE)
Goal 3:
Improve the safety of using medications.
2015 -National Patient Safety Goals
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ความเสยง ความปลอดภย คณภาพการก ากบดแลวชาชพสงแวดลอมในการดแลผปวยการปองกนการตดเชอระบบเวชระเบยนระบบจดการดานยาการตรวจทดสอบการเฝาระวงโรคและภยสขภาพการท างานกบชมชนกระบวนการดแลผปวย
การเขาถงและเขารบบรการการประเมนผปวยการวางแผนการดแลผปวยการใหขอมลและเสรมพลงการดแลตอเนอง
ดานการดแลผปวยดานการมงเนนผรบผลงานดานการเงนดานทรพยากรบคคลดานระบบและกระบวนการส าคญดานการน าดานการสรางเสรมสขภาพ
การน า
การวางแผนกลยทธ
การมงเนนผปวยและสทธผปวย
การวด วเคราะห และจดการความร
การจดการกระบวนการ
การมงเนนทรพยากรบคคล
ผลการด าเนนงาน
ตอนท IIIกระบวนการดแลผปวย
ตอนท II ระบบงานส าคญของ รพ.
ตอนท IV ผลการด าเนนงาน
ตอนท I ภาพรวมของการบรหารองคกร
มาตรฐานโรงพยาบาลและบรการสขภาพ ฉบบเฉลมพระเกยรต ฉลองสรราชสมบต ครบ 60 ป
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ความเชอมโยงกบระบบการจดการดานยาในโรงพยาบาล
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มาตรฐานโรงพยาบาลและบรการสขภาพ ฉบบเฉลมพระเกยรตสรราชสมบตครบ 60 ป ฉบบปรบปรง มกราคม 2558
ความเชอมโยงกบระบบการจดการดานยาในโรงพยาบาล
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A medication error is “any preventableevent that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”
(The National Coordinating Council for Medication Error Reporting and Prevention, 1998)
Medication Error : Definition
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Medication Error : Definition
คอ เหตการณใดๆทสามารถปองกนได ทอาจเปนสาเหตหรอ
น าไปสการใชยาทไมเหมาะสม หรอเปนอนตรายแกผปวย ในขณะท
ยาอยในความควบคมของบคลากรสาธารณสข ผปวยหรอผรบบรกการ
(ธกดาและคณะ , 2548)
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Administration error : Definition
การใหยาทแตกตางไปจากค าส งการใชยาของผส งใชยา
ทเขยนไวในบนทกประวตกการรกษาผปวย
ความคลาดเคลอนทท าใหผปวยไดรบยาผกดไปจากความ
ตงใจในการส งใชยาของผส งใชยา
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Near miss, Close call: ISMP Definition
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Medication Errors
are due to multiple factors in a complex of medical system.
“In most cases, medication error
can’t be blamed on a single person.”
(Paul Seligman, 1993)
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Medication Errors
Recommended that effective interdisciplinary teams “ attending to one another’s safety concerns”.
• Errors in health care should be seen as the result of complex systems rather than the fault of individual clinicians.
(IOM,1999)
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มมมองความผดพลาดตางกนท าใหการจดการตางกน
• หากบคลากรแตละวชาชพ ไดรบการฝกฝนมาด
แนวคดเชงบคคล แนวคด
ดงเดม
• เชอวามนษยทกคนสามารถท าผดไดยอมรบขดจ ากดของมนษย
แนวคดเชงระบบ
แนวคดใหม
จะปฏบตหนาทไดอยางสมบรณแบบ
No error
Active error จากตวบคคล
การปองกนความคลาดเคลอน ,ลง
โทษ,ตกเตอนปกปดความผด
No error
Latent error ความบกพรองของระบบทม
มากอน
การปองกนความคลาดเคลอนตองเปลยน
สงแวดลอมหรอระบบงาน
เสยโอกาสการน าความผดพลาดมา
วเคราะหเพอแกไขเชงระบบ
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Every 5 doses = ERROR
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How many die from medical
mistakes in US Hospitals?1999 IOM “To Err is Human” …. 98,000 /year
2010 The department of Health and Human services
.... 180,000 /year
2013 The Journal of Patient Safety 210,000-400,000
/year
Medication Errors
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48% of errors caught
before reaching patientOnly 2% of errors caught
before reaching patient
Ordering Transcribing Preparing Administering
39% errors 12%errors 11%errors 38%errors
Leape LL et al. “Systems analysis of adverse drug events,” JAMA, 274: 35-43, 1995.
Errors พบไดในทกกระบวนการบรหารยา?
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ตวอยาง Medication Errors : FDA
One patient died !!because 20 units of insulin. โดยแพทยเขยนค าสงยอ insulin 20 u
ผปวยเขาใจผดวา u คอ 0
ผล ผปวยฉด insulin 200 units
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An elderly patient with rheumatoid arthritis died
after receiving an overdose of methotrexate 10 mg OD ซงควรไดรบ 10 mg weekly
ตวอยาง Medication Errors : FDA
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SDMC
InjectableMedication
Errors
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Injectable Medication Errors
•90 % of hospitalized patient ไดรบ infusion therapy• เกด Error ไดในทกขนตอน มกกอใหเกดอนตรายทรายแรงขนกบ• คณสมบตของยาแตละชนด• Complexity ของ therapeutic action ของยานนๆ
•Significant risk Injury death
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Ross LM, et al (2000) ศกษา Retrospective IOR med error ใน UK 5 ป พบวา
56 % ของการเกด IV medication error สามารถปองกนได 59 % เกดจาก Nurse Administration ทเกยวของกบ
• Dose• Concentration
Kaushal R, et al.(2001) 54 % ของเดกท admit มโอกาสเกด ADEs
Injectable Medication Errors
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Injectable Medication Errors
ANA (2007) ศกษา IV medication error(n=1039)
• 99 % เกด serious effects
• 48 % เกดจาก • Drug preparation• IV medication administration
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73 % เปน error จาก IV bolus administration
95 % เปนการ bolus dose ทเรวกวา recommendation
และเมอวเคราะหสถานการณพบวา เกดจาก
Inadequate training :preparation and IV administration
Lack of knowledge of medication selection and preparation
Taxis K, Barber N.(2003)
ศกษาใน ร.พ. 2 แหง ใน UK (10 ward)
พบวา 41.9 % หลงเกด Error ตองเฝาระวงตออยางใกลชด
Injectable Medication Errors
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Pitfall: Tuberculin VS Insulin syringe
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Insulin syringe
These syringes are marked in increments of 0.01 cc. And the needles are often 26 to 27 gauge in diameter and 1/2 to 5/8 inch in length. ... Insulin Syringes can not be used in place of a Tuberculin Syringe because the units of measure are different and the needle of a TB Syringe is shorter than that of an Insulin Syringe.
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Tuberculin
These syringes are marked in increments of 0.01 cc. And the needles are often 26 to 27 gauge in diameter and 1/2 to 5/8 inch in length. ... Insulin Syringes can not be used in place of a Tuberculin Syringe because the units of measure are different and the needle of a TB Syringe is shorter than that of an Insulin Syringe.
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Pitfall: Labelling
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Labelling container: SyringePatient name , Drug name , Dose
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KCL
Labelling container: ตดฉลากยาเมอผสมยาทนท
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SDMC
Medication Errors
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สาเหตของความคลาดเคลอนจากการใชยา
• การไมเขาใจถงแนวทางปฏบตในการ บรหารยาของโรงพยาบาล • ภาระงานทมาก มกพบความคลาดเคลอนในการใหยา โดยเฉพาะการใหยาผด
เวลาและ การใหยาฉดดวยอตราเรวทผด • การสอสารทไมสมบรณ ระหวางผสงใชยา ผจายยา ผใหยา และผปวยใน
กระบวนการใชยา • การขาดระบบการตรวจสอบซ าจากบคคลอน เมอมการเตรยมยาในหอผปวย• การสงยาของแพทยดวยลายมอ ทอานยาก หรอการสงโดยวาจาทอาจไม
ชดเจนพอและไมม การยนยนค าสงโดยเรว หรอการคดลอกรายการยาทผดพลาด
Barker KN, McConnell WE. The problem of detecting medication errors in hospital. AM J Hosp Pharm 1962;19: 360-9.
Perlstein PH, Callison C, White M, et al. Errors in drug computations during newborn intensive care. Am J Dis Child 1979;133: 376-9.
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สาเหตของความคลาดเคลอนจากการใชยา
• การขาดการจดการระบบยาทด เชน การจายยาไปยงหอผปวยไมทนเวลา ท าใหผปวยไดรบยาไมตรงเวลา
• การขาดความรเกยวกบยาทแพทยสงใช
• การขาด ขอมลจ าเพาะของผปวย เชน ประวตการแพยา ซงจ าเปนตอการประเมนความเหมาะสมของการใชยา
• การไดรบยาผด ขนาด เนองจากความสบสนในหนวย ความซบซอนในการ
ค านวณขนาด
• การเตรยมยาไมถกตอง เชน หยบยา ผดขนาด การเจอจางดวยตวท าละลายทไมเหมาะสม การบดยาทหามบดแบง เปนตน
Barker KN, McConnell WE. The problem of detecting medication errors in hospital. AM J Hosp Pharm 1962;19: 360-9.
Perlstein PH, Callison C, White M, et al. Errors in drug computations during newborn intensive care. Am J Dis Child 1979;133: 376-9.
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กลยทธ การออกแบบระบบการดแลผปวยทปลอดภย
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SDMC
ISMP Guideline
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SMART NURSES…SMART CARE
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SMART NURSES…SMART CARE
ISMP Guideline
Standard Concentrations ofNeonatal Drug Infusions
For• Reduce medication error risk เมอยายผปวย• Stimulate development of standardized infusion device
drug libraries• Preparation standard solutions
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMC
Standard Administration Time schedules
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Standard Administration Time schedules
Type of Scheduled Medication Goals for Administration Time
Time-Critical Scheduled Medication
Hospital-defined time-critical medicatione.g. insulin
Within 30 minutes before or after the schedule time
Non-Time-Critical Scheduled Medication
Daily, weekly, monthly medication
Within 2 hours before or after the schedule time
Medications prescribed more frequency than daily, but nomore than q 4 hrs.
Within 1 hours before or after the schedule time
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SMART NURSES…SMART CARE
Standard Administration Time schedules
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Excellent position to detect and report medication errors
Final point in check and balances triad(Physicians, Pharmacists and other Nurse)
Guideline on preventing medication error
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SMART NURSES…SMART CARE
Pathway for medication safety
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Pathway for medication safety
Pharmacy Information
System
Electronic Medication
Record
Bar code enabled point
of care
Computerized Prescriber
Order Entry : CPOE
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SMART NURSES…SMART CARE
Standard
order set
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SMART NURSES…SMART CARE
Standard Order Set
Designed standard order set Electronic formats : CPOE system Paper formats : Pre-print order forms
For
Best practices communicating through multidisciplinary
Reduce the potential for medication errors Reduce unnecessary calls to physicians
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SMART NURSES…SMART CARE
CPOE System
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ระบบการสงยาเคมบ าบดโดยแพทยผานระบบสารสนเทศ
โปรแกรมสงยาเคมบ าบด Online ( CPOE)
ตรวจสอบสทธออนไลน ลงทะเบยน/นดหมายรอบตอไป
EMR
เวชระเบยนแบบออนไลน Preprint Order Preprint MAR
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMCPre-print order
forms
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMCPre-print MAR
forms
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMC
Pre-print Nurse Kardex forms
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ระบบยา
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMCIndependent
Double check
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SDMC
การทวนสอบขณะรบยา
Double check order กอนใหยา
Patient Identification
Double check rate กอนและ
ระหวางใหยา
สรางระบบทวนสอบในทกกระบวนการ
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMC Patient Identification
before Medication Administration
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SDMCใหญาตผปวยมสวนรวมในการ Identified
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SMART NURSES…SMART CARESmart Nurses…Smart Care
SDMCBedside Bar-Coding Technology for Drug
Administration System
Patient information
Drug information
Communication of drug orders and MARS
Staff competency and education :
special training
• Common database with the pharmacy system• Single MARS• Available at patient bed side• Standard administration times• Password for all nurses
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Reduce the risks of High Alert Drugs
1.Standardize process to prevent errors
• computerized prescriber order entry (CPOE) systems ,preprinted orders forms, or ordering protocols
• bar coding
• “smart” pumps that have a drug library requiring confirmation
of drug dose limits before they’ll start infusing medication.
• Use dosing and infusion rate charts in patient-care units.
• Standardize/limit drug concentrations and formulations.
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2.Practice drug differentiation
Using “tall-man” lettering for look-alike drug names Ex. DoPAmine , DoBUTamine
3.Restrict high-alert drugs and administration routes. Ex KCL
4.Make patient information readily accessible
5.Include patients in therapy
Reduce the risks of High Alert Drugs
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6.Apply reminders
Reduce the risks of High Alert Drugs
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7.Make errors apparent
• Perform independent double checks. Having another person review the steps you
follow to prepare or administer a medication can uncover a mistake and possibly save a patient’s life. According to facility policy, you may have to add your signature to the MAR to indicate your verification
8.Minimize the consequences of errors
• Store smaller vials of risky drugs
• Closely monitor the patient
Reduce the risks of High Alert Drugs
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SMART NURSES…SMART CARESmart Nurses …Smart Care
DMCS
RIGHTS OF MEDICATION ADMINISTRATION
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SMART NURSES…SMART CARESmart Nurses …Smart Care
DMCS
Right patient
Right drug
Right dose
Right routeRight
technique/Document
Right time
The six Rights
Medication administration
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SMART NURSES…SMART CARESmart Nurses …Smart Care
DMCSThe SixRights
The SevenRights
The Eight Rights
The NineRights
The TenRights
The TenRights
1 Right patient Right patient Right patient Right patient Right patient Right patient
2 Right drug Right drug Right drug Right drug Right drug Right drug
3 Right dose Right dose Right dose Right dose Right dose Right dose
4 Right route Right route Right route Right route Right route Right route
5 Right time Right time Right time Right time Right time Right time
6 Right Documentation/
Technique
Right Documentation/
Technique
Right Documentation/
Technique
Right Documentation/
Technique
Right Documentation/
Technique
Right Documentation/
Technique
7 Right reason Right reason Right action Right Client Education
Right reason
8 Right response Right response Right to Refuse Right Monitoring
9 Right form Right Assessment Right Flow rate( Intraveneous)
10 Right Evaluation Right Dilution or Compatibility
( Intraveneous)
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SMART NURSES…SMART CARE
Rights of Medication Administration
1. Right patient
• Check the name on the order and the patient.
• Use 2 identifiers.
• Ask patient to identify himself/herself.
• When available, use technology (for example, bar-code system).
2. Right medication
• Check the medication label. Label all medications, medication containers (i.e. syringes, medicine cups, basins) or other solutions on or off the sterile field.
• Check the order.
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3. Right dose
• Check the order.
• Confirm appropriateness of the dose using a current drug reference.
• If necessary, calculate the dose and have another nurse calculate the dose as well.
4. Right route
• Again, check the order and appropriateness of the route ordered.
• Confirm that the patient can take or receive the medication by the ordered route.
Rights of Medication Administration
SMART NURSES…SMART CARE
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5. Right time and frequency
• Check the frequency of the ordered medication.
• Double-check that you are giving the ordered dose at the correct time.
• Confirm when the last dose was given.
6. Right documentation
• Document administration AFTER giving the ordered medication.
• Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.
• very important for rtPa, conscious sedation and the right documentation usually includes forms to help or know the "right monitoring“
Rights of Medication Administration
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7. right technique
8. right monitoring
important for potassium, Dilantin, nitroglycerine drips, chemo drug, etc. record vital sign within 15 minthen 30 min x 2 and q 1 hr
9. right flow rate ( intravenous )
important for insulin chemo drug and Heparin drips
10. right dilution or compatibility ( intravenous )
important for antibiotics chemo drug
Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.
Rights of Medication Administration
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SMART NURSES…SMART CARE
Ramathibodi Strategies
Using technology
Improving processes
Zeroing in the errors that cause harm
Building a culture of
safety
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กลยทธ ท 1 ออกแบบระบบเพอปองกนความคลาดเคลอน
ระบบสงยา
• จดใหมระบบการสงยาใหแกหอผปวยอยางสม าเสมอ (unit dose, one day dose, three day dose)
• จดใหมระบบการจดสงยาดวน ภายใน 15-30 นาท เพอลดยาส ารอง ลดโอกาสการหยบยาผดของพยาบาล
Technology
• จดใหมตยาอตโนมตจดเกบยาทส าคญ เชน ยาเสพตด ยาจ าเปน
• มระบบเครองจาย จดยาอตโนมต• มระบบขอมลสนบสนน• Smart Infusion pump• ระบบ CPOE
การส ารองยา• ไมเกบ electrolyte conc. ไวทหอผปวย
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กลยทธท 2 ออกแบบวธปฏบตทสงผลใหสามารถตรวจพบความคลาดเคลอนได
Recheck
• การตรวจสอบ 2 ครง (Independent Double Check)
Monitoring
• การตดตามผลของการใหยาแกผปวยและลงบนทก
Education
• การแนะน าและใหความรแกผปวยเกยวกบยาและแผนการรกษา
• การใหความรแกเจาหนาทเกยวกบการบรหารยา ความรเรองยา การใชอปกรณและเทคโนโลย
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กลยทธท 3 การบรรเทาผลของความคลาดเคลอนเพอลดอนตรายทอาจเกดขน
Early detection
• Phlebitis Monitoring
Emergency response
• Extravasation management
• Anaphylactic kit
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2010
2013
2014 20172015
HAD and Medication Safety Management
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SMART NURSES…SMART CARE
Technology to Reduced Medication Errors SMS program
เครองจดและบรรจซองยาอตโนมต
Barcode : identify
Pharmacy IV Admixture Service ( PIVAS)Computerized physician order entry (CPOE)
NFC/QR code
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SMART NURSES…SMART CARE
SIMPLE
Patient Safety Goalsเขมมงดานการบรการรกษาพยาบาล 2558-2559
Medication
Reconciliationเปาหมาย
• สหสาขาวชาชพท า MR ≥ 80 %• ความแตกตางของรายการยาโดยไม
ตงใจ≤ 10 %
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SMART NURSES…SMART CARE
ลดความผดพลาดจากการบรหารยาในกลม ทมความเสยงสงดวยการใชเทคโนโลย Smart Pump
Safety medication โดยใช functions เชน• Drug library function
- ระบขอมลจ าเปนในการบรหารยาแตละชนด
- ก าหนด Therapeutic range• Sequential function
- ส าหรบการtitrate ยาเชน Chemotherapy , Antibiotic
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SMART NURSES…SMART CARE
Smart pumps are not smart on their ownALERT !!!!
• Bypass the drug library
• Must know how to use drug library• Correct weight• Correct dilution• Correct drug• Correct unit (ex. prescribe as mg/min, in library as
mg/hr)
• Addition to medication safety, not a replacement for critical thinking
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SMART NURSES…SMART CARE
Visual control
Safe Practice for IV medication
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SMART NURSES…SMART CARE
Safe Practice for IV medication
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SMART NURSES…SMART CARE
Safe Practice for IV medication
Example
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Ready to use Sticker for 3 objectivesBag /Syringe type
Infusion type
IV line type
Monitoring
สตกเกอรส าหรบตดหนาเครองInfusion pump
สตกเกอรส าหรบตดbag
สตกเกอรส าหรบตด IV site ex. Portฉดยา,3ways
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SMART NURSES…SMART CARE
Ready to use Sticker : HAD infusion
สตกเกอรส าหรบตดbag
สตกเกอรส าหรบตดหนาเครองInfusion pumpสตกเกอรส าหรบตด IV site ex. Portฉดยา,3ways
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SMART NURSES…SMART CARE
1.IV Bag
2.Infusion pump
3.IV line ดานใกลผ ปวยบรเวณport ฉดยาหรอ 3-ways
มาตรฐานต าแหนงการตดสตกเกอร
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SMART NURSES…SMART CARE
Ready to use Sticker : Do and Don’t
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SMART NURSES…SMART CARE
Labelling : Syringe Labelling
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SMART NURSES…SMART CARE
Other
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SMART NURSES…SMART CARE
Example: Color code syringe
For Oral use only
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SMART NURSES…SMART CARE
Example: Color code syringe
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SMART NURSES…SMART CARE
เภสชกรเตรยมยาและHighlight route
ตด Routeบรหารยาทตว syringe
Highlight Route ทฉลากยาตามสทก าหนด
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SMART NURSES…SMART CARE
เภสชกรเตรยมยาและHighlight route
ตด Routeบรหารยาทตว syringe
Highlight Route ทฉลากยาตามสทก าหนด
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SMART NURSES…SMART CARE
Vincristine
• Antineoplastic Agent, Vinca Alkaloid
• Acute lymphocytic leukemia (ALL): Central nervous system tumors,Hodgkin lymphoma , Non-Hodgkin etc.
• For I.V. administration only. FATAL IF GIVEN INTRATHECALLY
• Vesicant (Avoid extravasation)
• Common ADR: Neurotoxicity, Peripheral neuropathy
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SMART NURSES…SMART CARE
U.S. Boxed Warning
• Not for intrathecal administration For I.V. administration only; inadvertent intrathecaladministration usually results in death.
-To prevent administration errors, recommends dispensing vincristine diluted in a minibag (WHO, 2007)
- Label “For intravenous use only”- fatal if given by other routes
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SMART NURSES…SMART CARE
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SMART NURSES…SMART CARE
Change Order to Change Package
Chemotherapy
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SMART NURSES…SMART CARE
Pre-Mixed KCl
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SMART NURSES…SMART CARE
IV Nurses : Daily Round & Monitoring
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SMART NURSES…SMART CARE
Pharmacist : Consultation
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SMART NURSES…SMART CARE
Sharepoint : การเขาถงเอกสารคณภาพเกยวกบยา
1
เภสชกรรม(ฝาย)
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SMART NURSES…SMART CARE
Shortcut HADs
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SMART NURSES…SMART CARE
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SMART NURSES…SMART CARE
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SMART NURSES…SMART CARE
NEW ! WI การเตรยมและบรหารยาทมความเสยงสง
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SMART NURSES…SMART CARE
แนวปฎบตการรบค าสงทางวาจา / โทรศพท
Write downRead back
Confirm
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SMART NURSES…SMART CARE
จดท าแนวปฎบตการรบค าสงทางวาจา / โทรศพท
Order by phone verbal
Date ___________Time____________
Read/Repeated to MD. ___________
By RN1 __________ Code _______
Confirm by RN2 ________ Code _______
Cosign by MD __________ Code _______
Date _____________ Time ____________
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SMART NURSES…SMART CARE
MAR
Time Sign
9.10 RN1/RN2
18 RN1/RN2
21.15 RN1/RN2
หลกฐานการทวนสอบใน Document
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SMART NURSES…SMART CARE
Nurse progress note 1
หลกฐานการทวนสอบใน Document
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SMART NURSES…SMART CARE
Nurse progress note 2
หลกฐานการทวนสอบใน Document
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SMART NURSES…SMART CARE
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SMART NURSES…SMART CARE
สรางสงใหม เพอขจดจดเสยง และลดภาระงาน
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SMART NURSES…SMART CARE
Phase 1
Phase 2
Phase 3Phase 4
EMAM
การพฒนาระบบ EMAM
EMAM = Electronic Medication Administration Management
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SMART NURSES…SMART CARE
EMAM process
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SMART NURSES…SMART CARE
EMAM process
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SMART NURSES…SMART CARE
EMAM process
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SMART NURSES…SMART CARE
EMAM process
การแพยา : แตะส าหรบรายละเอยด
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SMART NURSES…SMART CARE
Electronic MAR
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SMART NURSES…SMART CARE
การเขาถงฐานขอมลยาผานInternet: wifirama,mu,internetทเขาผานคอมพวเตอรคณะฯ
พมพMicromedex solution
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SMART NURSES…SMART CARE
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SMART NURSES…SMART CARE
ระบบการรายงานอบตการณ
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SMART NURSES…SMART CARE
Medication Administration HAD Chemo Therapy & Medication error
ฝกจดยาและ Double check
Goal 3 Safety of Medications
การดแลผปวยไดรบยาเคมบ าบด, Port Care
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SMART NURSES…SMART CARE
NURSES & CARE
SMAR
TQUESTIONS