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Update on Medication Errors and Adverse Drug Events - A Florida Board-Approved CE Activity

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Overview

Interest in medication errors was heightened by publication of the Institute of Medicine (IOM) report “To Err is Human,” which revealed the burden of medical errors and the impact on patients in the US. Following publication of the report in 2000, health care organizations bolstered efforts to reduce medical errors and the illness and death that result. Despite these efforts, a recent analysis based on studies conducted since the IOM’s report highlighted medical errors (including medication errors) as the third leading cause of death in the US. Extrapolating to the total number of US hospital admissions in 2013, the authors estimated that more than 250,000 deaths per year are caused by medical errors – and that includes only inpatient deaths.

Medication errors have been identified as the most common type of medical error. The FDA estimates that medication errors occur in about 1.3 million people annually and result in at least one death every day in the US. In the hospital setting, adverse drug events (ADEs) occur in nearly 5% of patients; preventable ADEs are one of the most common types of inpatient errors. In the outpatient setting, ADEs account for more than 3.5 million physician office visits, 1 million emergency department (ED) visits, and 125,000 hospital admissions annually. It is estimated that nearly half of these ADEs are preventable. Given the impact of medication errors and ADEs on healthcare utilization and costs in the US, error prevention practices remain key for both prescribers and pharmacists. Because pharmaceutical care involves the identification, resolution, and prevention of drug therapy problems and medication errors, pharmacy personnel, as well as prescribers and patients, have a key role in error prevention.

This issue provides background information on medication errors and ADEs, and discusses medication error identification and prevention...

Details

Publication Date: 05/20/2017
Expiration Date: 05/20/2020
CE Credit: 2.0 (0.2 CEU)
Type of Activity: Knowledge-based

This program was developed by The Rx Consultant and published by Continuing Education Network, Inc. The Rx Consultant accepts no advertising or financial support from the pharmaceutical industry and is funded solely by the purchase of programs. The Rx Consultant is dedicated to providing unbiased, balanced information to health care practitioners.

Programs developed by The Rx Consultant are written by health care providers with expertise in the topic area, peer-reviewed, extensively edited, and fact-checked. This development process was created to insure that every program presents information that is current, accurate, relevant to "real world" health care providers, and written in an easy reading, "plain English" style.

Authors

Joshua J. Neumiller, PharmD, CDE, FASCP is Vice- Chair and Associate Professor of the Department of Pharmacotherapy, College of Pharmacy, Washington State University in Spokane Washington.

Kelly Ann Tanaka is a PharmD candidate of the Department of Pharmacotherapy, College of Pharmacy, Washington State University in Spokane Washington.

Disclosure Statement

Dr. Neumiller and Ms. Tanaka report no financial relationship with the manufacturer(s) or provider(s) of any commercial product(s) or service(s) that appear in this issue.

Target Audience

This accredited program is targeted to pharmacists and nurses.

Goals & Objectives

At the conclusion of this program, participants will be able to:

    1. Discuss the steps in the medication use process and the types of medication errors that may occur. Describe the relationship between medication errors and adverse drug events (ADEs). List the drug classes that are prone to emergency department visits due to ADEs.
    2. Describe the main recommendations from national organizations (eg, IOM, ASHP, JCPP, and DHHS) for improving medication safety. List the steps involved in the Pharmacists' Patient Care Process (PPCP) and specific risk reduction strategies to prevent medication errors recommended by the ISMP.
    3. Review the evidence supporting pharmacist interventions to improve medication safety, including adherence, and reducing medication discrepancies during transitions of care.
    4. Discuss how the use of health information technology (HIT) can have a positive impact on medication safety. List possible disadvantages of HIT.

Accreditation Statements

The Rx Consultant is a publication of Continuing Education Network, Inc.

Continuing Education Network, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education as a provider of continuing pharmacy education.

Continuing Education Network is approved by the California Board of Registered Nursing, Provider Number CEP 13118. Programs approved by CA BRN are accepted by most State Boards of Nursing.

ACPE Universal Activity Number: 0428-0000-17-006-H05-P


Exam & Credit Statement Procedures

Upon successful completion of this program and the post test (70%), 2.0 hours of continuing education credit will be awarded. To receive credit and your exam score, please complete the exam questions and program evaluation.

Editorial and Review Board

Chief Editor and CE Administrator


Terry M. Baker, PharmD

Managing Editor


Tracy Farnen, PharmD

Associate Editors


James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Kaiser Permanente
Oakland, CA

Associate Clinical Professor
School of Pharmacy
University of California San Francisco
San Francisco, CA

Richard Ron Finley, B.S. Pharm.,R.Ph.
Clinical Pharmacist (volunteer faculty)
University of California, San Francisco (UCSF) Memory and Aging Center
Lecturer (Emeritus) UCSF, Department of Clinical Pharmacy
Health Sciences Clinical Professor, UCSF School of Pharmacy
San Francisco, CA

Consultant Pharmacist
Ray Dolby Brain Health Center, Sutter Health/CPMC
San Francisco, CA

Consult Pharmacist Aging and Adult Health Services
San Francisco Health Department
San Francisco, CA

Julio R. Lopez, PharmD, FCSHP
Chief of Pharmacy Service
VA Northern California Health Care System

Adjunct Clinical Professor
College of Pharmacy
Touro University
Vallejo, CA

Assistant Clinical Professor
School of Pharmacy
University of California, San Francisco
San Francisco, CA Adjunct Professor
Thomas J. Long School of Pharmacy
University of the Pacific
Stockton, CA

Visiting Associate Professor and Lecturer
Nursing School
Samuel Merritt University
Oakland, CA

Pamela Mausner, MD

Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Detroit, MI

Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Detroit, MI

Senior Editorial Advisor


Gerard Hatheway, PharmD, PhD

Editorial Advisors


Belinda M. Danielson, RPh
Christopher M. DeSoto, PharmD
Angie S. Graham, PharmD
Cynthia Chan Huang, PharmD, MBA
Fred Plageman, PharmD

Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners


Emily K.
Meuleman, RN, C, MS

About the Rx Consultant

The Rx Consultant is a monthly publication dedicated to providing health care professionals with the information they need to educate patients about drugs and manage drug therapy. The reader is responsible for confirming the information presented here and interpreting it in relation to each patient's specific situation before utilizing the information.

Technical Specifications

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This includes Microsoft Internet Explorer 11, Google Chrome 38, Google Android OS 5.0 Browser, Apple Safari (version 7 for desktop, 5 for mobile), Mozilla Firefox 27, newer versions of these browsers, as well as some earlier versions that may require additional configuration.

Adobe Acrobat Reader is recommended, and is required for some browsers.

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Internet Connectivity

Required. Broadband recommended. (T1, DSL, Cable, G4 or higher.)

Contact Us

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