ROVA HMR MAGAZINE:

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The

July

Effect

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SCHEME CE

TIONAL H NA E

N

T H IN S U R A AL

hfn ENGAGEMENT

PMG

ACCESS

QUALITY

MAN

Pharmaceutical Manufactures Group of Manufacturers Ass. of Nig. (PMG-MAN)

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Louis Lasagna

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INTERVIEW PATIENT SAFETY AND MANAGING

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Year

2011

2012

2013

2014

Report no.

3081

2404

2316

988

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�

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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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Credit

James Reason, Professor of Psychology Healthcare Management Review PAGE Volume 11 111

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Crew Resource

Management From

Aviation

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To

Medicine

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Mrs. W Story Line

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The ‘'two-challenge rule:"

Dr. Benjamin Sachs, is the hospital's chief of obstetrics and gynecology, at Beth Israel Deaconess Medical Center

Implementation Process

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The core The coordinating The contingency

TEAM

Credit: John M. Eisenberg Patient Safety and Quality Awards.

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There are evidence supporting the premise that direct participation of pharmacists' in clinical care reduces medication errors and ADEs in hospitalized and ambulatory patients.

Credit Rainu Kaushal, M.D., M.P.H. David W. Bates, M.D., M.Sc. Harvard Medical School

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I

t was a busy Sunday in the pharmacy at Rainbow Babies & 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 flowing 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 eventually 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 fine, and 400 hours of community service. I also lost my license, career, reputation, and

confidence. 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 fixing 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 fill 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 OďŹƒcer, CDC.

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THE "4 ELEMENTS" OF AN AE CASE 1 An identifiable patient,

3 A suspect drug,

2 An identifiable reporter,

4 An adverse event.

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Spontaneous

Reporting

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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

Credit

Pharm (Mrs) A.I Osakwe (Fmr) National Coordinator, NATIONAL PHARMACOVIGILANCE CENTRE {NPC}

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PHARMACOVIGILANCE OF

ANTIRETROVIRAL

MEDICINES

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Credit

Dr. Peter U Bassi MBBS, MSc, FMCP (Nig.), Consultant Physician/Clinical Pharmacologist, University of Maiduguri Teaching Hospital, North East Zonal Pharmacovigilance Coordinator.

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CONSUMER AWARENESS ON REGULATED PRODUCTS

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Credit

M.O. Akhigbemidu Assistant Chief Regulatory OfďŹ cer, Advert Control/Consumer Affairs Unit, Registration & Regulatory Affairs Directorate NAFDAC, Oshodi Lagos.

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PROMOTING THE QUALITY OF MEDICINES

Factory Address:

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