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All human-beings are fallible. The old adage “To Err Is Human” also applies to Medication Management Systems, especially, when it comes to designing its processes, safely and seamlessly. Even system-based errors are rooted in human errors & follies. Distractions & failure to pay attention, at a decisive moment, beget errors. These will be inevitable & inevasible as long as people are involved in the processes of Medication Management Systems. Errors that crop up, during resolution of problems, are conscious, complicated & largely the byproduct of ignorance, lack of staff-training, poor systems, incoherent procedures & subsequent adherence to the same. Safe medication management can be achieved, if an organization also steps in, helping its people run the processes soundly & efficiently. Systematic & certain external environmental factors can vastly reduce & control human errors. An organization can easily forge an environment, conducive to its employees’ holistic development, growth & efficacy, if it minimizes commotion in its premises, lessens distractions & cranks up its lighting. All these active steps enable employees to concentrate harder on their assignments. Lack of understanding of patient-specific information can also thwart an employee’s ability to make an informed & sound choice. Miscalculations of doses can lead to fatal outcomes for patients. Moreover, errors can also stem from incomplete & complicated orders. Education of staff, therefore, becomes indispensable for evasion of errors. In every organization, a calculation check should be mandatory. Equally important is the role of an organization in explaining, clarifying & defining a flawless & complete order. When a pharmacist is checking the calculations pertaining to medication doses, he must not skip any of the steps, involving calculations & should preferably redo them before comparing them with their results. Whenever new gadgets or medications are introduced in an organization, its staff needs to be thoroughly trained on the same. Active participation of patients and their education in the entire medication management process can help beat the odds. Transcription of errors can be traced back to miscommunication. If a robust & steady checking process is in place, throughout, errors, while transcribing orders to the medication administration record, can largely be avoided. Moreover, special preventive & precautionary strategies must be adopted to alleviate hazards that are inextricably associated with highrisk medicines. Each organization should have its own quintessential method of categorizing risky medicines & isolating the ones that look & sound the same. While administering medicines to patients, an organization must ideally deploy two patient identifiers, instead of one, who can work at peace, uninterrupted & focused, in a quiet ambience. Efficient & consistent monitoring of patients takes into account all the negative effects, side effects & toxicity of particular genres of medications, thus promoting safer Medication Management Systems. The key to successful MMS is to employ safety ploys at each risk point as well as strategies that will allay the harm caused by any error.
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Certain processes, due to their unique architecture & functionalities, are susceptible to errors. As for instances, processes with more variable inputs are most likely to commit errors. Moreover, the more complicated processes are, the more vulnerable they are to errors primarily because of the large number of steps, workarounds & disparities they involve. Simplification of processes, wherever viable, & standardization of operational procedures, can help tone down risks to a considerable extent. At times, when one step in the process commences immediately after the preceding step or before the proper completion of the previous step, it practically becomes impossible to undo the flaws, present in the steps before. Errors can be combated more systematically through collaborative team-work & effective reporting of near-misses & prospective errors. However, in a highly hierarchical team, errors may not be pointed out in fear of criticism or overstepping the authority of those in power. Under such circumstances, hierarchies must be removed without any hesitation, in order to ensure patient safety. In the wake of a grave medication error, a root cause analysis must be performed in order to understand what went wrong in the preceding steps & how they can be prevented in near future. In most of these cases, the system remains primarily responsible for the flaws. Often multifarious processes of high-risk systems fail simultaneously, aggravating errors. Ideally, with the aid of practical risk assessments, riskfactors in systems can be identified & scrutinized before anything goes awry. Failure Mode & Effects Analysis (FMEA) is one such risk analysis strategy that gauges the probability of risks or errors & the gravity of their impact on the patients, when they occur. It endeavors to uproot such errors before they can actually reach the patients. However, the entire success of Medication Management Systems boils down to a cross-functional team, where members always work unitedly towards a common goal. For more information please visit our website: http://www.sunknowledge.com/pbm-medication-therapy-management.html
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