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Tuesday, July 21, 2020 | History

2 edition of prevention of intrathecal medication errors found in the catalog.

prevention of intrathecal medication errors

Kent Woods

prevention of intrathecal medication errors

a report to the Chief Medical Officer

by Kent Woods

  • 348 Want to read
  • 12 Currently reading

Published by Department of Health in London .
Written in English


Edition Notes

StatementKent Woods.
ContributionsGreat Britain. Department of Health.
The Physical Object
Pagination18p. ;
Number of Pages18
ID Numbers
Open LibraryOL18847850M

However, many events appear to be related to mistaking IV vinCRIStine for an intrathecal medication, such as methotrexate, cytarabine, or hydrocortisone. 6,7,9, Other causes include: the mislabeling of syringes; bringing IV and intrathecal medications into a treatment area together; failing to administer vinca alkaloids in a specialty.   Most reported errors have been inadvertent ICC administration of an injection intended to be parenterally administered, including bortezomib, doxorubicin, daunorubicin, dactinomycin, videsine, and vincristine. 7,8 Inadvertent ICC administration of vincristine and bortezomib is almost always fatal or causes severe neurologic injuries. 7,

  A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than million Americans are injured every year in American hospitals, and the. should never be administered by the intrathecal route because it is almost always fatal. Unfortunately, whilst emergency treatment was provided very quickly in an effort to rectify the error, Mr Jowett died at am on the 2nd February Following an Internal Inquiry at QMC into the circumstances surrounding the death of Mr Jowett, I was.

Preventing Vincristine Sulfate Medication Errors. Published books and journal articles, online newslet- The major toxicity associated with vincristine is neurotoxicity. ters and documents, pharmaceutical manufacturers' package inserts, and. in preventing accidental intrathecal vincristine administration. sion. Preventing Intrathecal Chemotherapy Errors: One Institution's Experience Article in Clinical Journal of Oncology Nursing 13(3) July with 14 Reads How we measure 'reads'.


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Prevention of intrathecal medication errors by Kent Woods Download PDF EPUB FB2

Strategy to adopt (i) if it prevented intrathecal medication errors with greater certainty than any human factor approach; (ii) if it prevented a wider range of adverse events than intrathecal Vinca alkaloid administration alone.

Levels of intervention for the prevention of errors Two broad preventive strategies are distinguished here. The Prevention of Intrathecal Medication Errors: A report to the Chief Medical Officer Technical Report April with Reads How we measure 'reads'.

Medication Errors is the most comprehensive, a01itative examination of the causes of and means to preventing medication errors in print. It helps readers understand the system-based causes of medication errors, including pharmaceutical trademarks, drug packaging and labeling, and error-prone abbreviations and dose expressions, as well as the patients role in preventing medication errors.3/5(1).

Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event.

By Cited by: 4. Named one of the top titles of the year by Doody's Health Sciences Book Review Journal, this is most comprehensive examination of the causes of and means to prevent medication errors. Written by the leading pharmacist-expert in the United States and two dozen experts from medicine, nursing, risk management and the pharmaceutical industry, this book captures much of what is known about the.

al Fawaz, I.M. Fatal myeloencephalopathy due to intrathecal vincristine administration. Annals of Tropical Paediatrics, 12,   Buy The Prevention of Intrathecal Medication Errors: a Report to the Chief Medical Officer by Kent Woods (ISBN:) from Amazon's Book Store.

Author: Kent Woods. Errors have long been recognised as a problem with therapeutic medicines. These have been shown to occur in % of all prescriptions.

Route delivery errors, of which intrathecal vincristine delivery is one example (there are many other examples such as intravenous delivery of benzathine penicillin), account for 5% of medication errors 1 - Noble, J & Donaldson, L () The quest to eliminate intrathecal vincristine errors: a year journey.

Qual Saf Health Care, 2 - Shepherd, DA et al () Accidental intrathecal administration of vincristine, Medical and Pediatric Oncology 5: 3 - Woods K () Prevention of intrathecal medication errors. Defining medication errors 3 2 Medication errors 5 3 Causes of medication errors 7 4 Potential solutions 9 Reviews and reconciliation 9 Automated information systems 10 Education 10 Multicomponent interventions 10 5 Key issues 12 Injection use 12 Paediatrics 12 Care homes 13 6 Practical next steps   Sevgin Hunt, Joyram Chakraborty, Electronic Health Records in Hospitals: Preventing Dosing Errors in the Medication Administration Context, Advances in Human Factors and Ergonomics in Healthcare and Medical Devices, /_7, (), ().

Although chemotherapy is a well established treatment modality, chemotherapy errors represent a potentially serious risk of patient harm.

We reviewed published research from to to understand the extent and nature of medication errors in cancer chemotherapy, and to identify effective interventions to help prevent mistakes. Chemotherapy errors occur at a rate of about one to four per.

K. WoodsThe prevention of intrathecal medication errors: a report to the chief medical officer University of Leicester, England () Association of anaesthetist of Great Britain and Ireland [homepage on the internet].

Medication errors like these can happen in any healthcare setting. According to the landmark report “Preventing Medication Errors” from the Institute of Medicine, these errors injure million Americans each year and cost $ billion in.

1. Woods K. The prevention of intrathecal medication errors. A report to the Chief Medical Officer. Department of Health, London, 2. Teahon K, Bateman DN. A survey of intravenous drug administration by pre-registration house officers. British Medical Journal ; 3.

Ferner RE, Aronson JK. Medication errors, worse than a crime. First printing of Medication Errors: Causes and Prevention, a comprehensive book on the causes and prevention of drug mistakes, written by Michael Cohen and Neil Davis, ISMP cofounders.

ISMP’s work officially begins with a continuing column on medication safety in Hospital Pharmacy (now published by Thomas Land Publishers). Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event.

By recognizing untoward events occur, learning from them, and working toward preventing them. For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses. 24 Among doctors depression and exhaustion are important.

25, 26 Errors are more likely to occur when tasks are carried out after hours by busy, distracted staff, often in relation to.

Inc., and Institute for Safe Medication Practices (ISMP) Medication Errors Re-porting Program. Additional cases have not been reported but have prompted litigation or appeared in the media (Joint Commission on Accreditation of Health-care Organizations [JCAHO], ; Schulmeister, ).

Inadvertent intrathecal vincristine. Background. The report, "To Err is Human", from the Institute of Medicine estimated that betw patients die each year in the USA as a result of medical errors [].Although certain adverse events are unavoidable, many are preventable, with medication errors being a major cause of such accidents [].Medication errors may occur anytime and at any stage during the medication.

Medication Errors is the most comprehensive, authoritative examination of the causes of and means to preventing medication errors in print.

It helps readers understand the system-based causes of medication errors, including pharmaceutical trademarks, drug packaging and labeling, and error-prone abbreviations and dose expressions, as well as the Reviews: 3.Prevention of Adverse Drug Events.

The pathway connecting a clinician's decision to prescribe a medication and the patient actually receiving the medication consists of several steps: Ordering: the clinician must select the appropriate medication and the dose, frequency, and duration.Michael Cohen's Medication Errors, Second Edition (), brought together experts in pharmacy, medicine, nursing, and risk management to provide authoritative advice on the causes and prevention of errors.

NOW, the CORE CHAPTERS are presented in a NEW, abridged s: 1.