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Th e
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PMG MANPharmaceutical Manufactures Group of
Manufacturers Ass. of Nig. (PMG-MAN)
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hfn
QUALITYACCESSENGAGEMENT
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Louis LasagnaLouis LasagnaLouis Lasagna
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PATIENT SAFETY AND MANAGING
INTERVIEWINTERVIEWINTERVIEW
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Year 2011 2012 2013 2014
Report no. 3081 2404 2316 988
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Adapted from:
Nurses and Patient Safety
Discussion Paper by.
Canadian Nurses Association
and University of Toronto Faculty of Nursing
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Credit Richard I Cook, associate director,
Marta Render, director,
David D Woods, associate director
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Credit
Institute for Safe Medication Practices, 2006
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"Heavy perspiration, shortness of breath-his symptoms were textbook.
the only thing was, I hadn't read that chapter yet."
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Imagine this scenario:
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James Reason,
Professor of Psychology
Credit
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Crew Resource
ManagementManagementManagement
AviationF r o mF r o mF r o m
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MedicineT oT oT o
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Mrs. W
Story Line
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Implementation Process
Dr. Benjamin Sachs,
is the hospital's chief of obstetrics and gynecology,
at Beth Israel Deaconess Medical Center
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The 'two-challenge rule:"
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The core
The coordinating
The contingencyTEAM
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Credit:
John M. Eisenberg
Patient Safety and Quality Awards.
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Credit
Rainu Kaushal, M.D., M.P.H.
David W. Bates, M.D., M.Sc.
Harvard Medical School
There are evidence supporting the
premise that direct participation of
pharmacists' in clinical care reduces
medication errors and ADEs in
hospitalized and ambulatory patients.
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t was a busy Sunday in the pharmacy at Rainbow
IBabies & Children's Hospital. The hospital's computer system had been down for about ten hours before I started my shift, and because I was
teamed with a pharmacist who was fairly new to the
department, I had additional responsibility. But I'd
been in busy situations many times before. In fact, I had
14 years of experience.
But on this day, I made the mistake of not thoroughly
checking a saline-solution base that a technician had
prepared for a child's chemotherapy treatment. She
mixed it more than 20 times stronger than ordered, and
I didn't catch it. When a nurse administered it, the high
concentration of sodium chloride owing through the
child's veins made her brain swell and put her in a
coma. Three days later, she died. Her name was Emily,
and she was two years old.
I was eventual ly convicted of involuntary
manslaughter, for which I received six months of jail
time, six months of house arrest, three years of
probation, a $5,000 ne, and 400 hours of community
service. I also lost my license, career, reputation, and
condence. But most devastating of all is that I have to
live every day with the memory of that little girl.
I accept full responsibility for what happened. I should
have checked that solution more carefully. But there
are some facets of hospital and retail pharmaceutical
work that desperately need xing if similar tragedies
are to be avoided.
We should also take advantage of technology. There
are lots of look-alike, sound-alike medications that
come in small vials with tiny labels. A bar-code
scanning system, like the ones in supermarkets, would
supply an extra layer of safety.
But technology isn't enough; pharmacists and techs
need better working conditions. Pharmacies can be
cramped and the workload is often heavy. But studies
suggest that crowding and dim lighting make mistakes
more likely. So do interruptions, and the need to ll too
many prescriptions. Believe me, a lot of pharmacists
say a little prayer on their way home that an error didn't
slip through.
Credit Eric Cropp
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Reported by:
A Abubukar, MBBS, E Awosanya, DVM, O Badaru, PhD, S Haladu, DVM, P Nguku, MBChB, Nigerian Field Epidemiology and
Laboratory Training Program. P Edwards, MPA, R Noe, MN, MPH, M Teran-Maciver, MSN, A Wolkin, MSPH, L Lewis, MD, National
Center for Environmental Health; M Nguyen, EIS Ocer, CDC.
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1 An identiable patient,
2 An identiable reporter,
3 A suspect drug,
4 An adverse event.
THE "4 ELEMENTS" OF AN AE CASE
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Spontaneous
ReportingReportingReporting
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Adapted from Wikipedia
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PHARMACOVIGILANCE OF
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ACT ANTI-MALARIALS
Credit NAFDAC
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ANTIBIOTIC RESISTANCE
PHARMACOVIGILANCE &
Pharm (Mrs) A.I Osakwe
(Fmr) National Coordinator,
NATIONAL
PHARMACOVIGILANCE
CENTRE {NPC}
Credit
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PHARMACOVIGILANCE OF
ANTIRETROVIRALMEDICINES
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Dr. Peter U Bassi MBBS, MSc, FMCP (Nig.), Consultant Physician/Clinical
Pharmacologist, University of Maiduguri Teaching Hospital,
North East Zonal Pharmacovigilance Coordinator.
Credit
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CONSUMER AWARENESS
ON REGULATED PRODUCTS
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Credit
Assistant Chief Regulatory Ofcer, Advert
Control/Consumer Affairs Unit, Registration
& Regulatory Affairs Directorate NAFDAC,
Oshodi Lagos.
M.O. Akhigbemidu
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PROMOTING THE QUALITY OF MEDICINES
Factory Address:
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