Medication Errors: Understanding the Causes and Designing Effective Risk Management Strategies

The purpose of this module is to engage health care providers (prescribers), pharmacists, and other health care professionals in evidence based practices to avoid medication errors and enhance patient safety. Successful attainment of knowledge by the learner will enable improved awareness and lead to changes in clinical practice measures to overcome common causes of medication errors.  

Target Audience

This activity is intended for physicians, nurses, pharmacists, and other healthcare professionals.

Learning Objectives

Upon completion of this module, the learner should be able to:

  • Establish an understanding of contributing factors and epidemiology of medication-related patient safety events 
  • A discussion on current research on causality (root cause analysis) and human factors design features to mitigate them 
  • A review of best practice approaches in reducing errors in the inpatient and ambulatory setting (clinic and pharmacy) 
  • Identify systems level innovations in risk management strategies that can be used to minimize or prevent medication errors and equip professionals to manage the consequences when they occur 

Disclaimer 

The material presented in this continuing medical education program is being made available for educational purposes and does not reflect the official views or policies of the DC Department of Health unless explicitly stated.

Course summary
Available credit: 
  • 2.00 ACPE Pharmacist
    The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
  • 2.00 ACPE Pharmacy technician
    The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
  • 2.00 AMA PRA Category 1 Credit™
    The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 2.00 Completion
Course opens: 
10/23/2020
Course expires: 
10/23/2024
Rating: 
4

Allen J. Vaida PharmD, FASHP

Executive Vice President, Institute for Safe Medication Practices

Bio:

Allen J. Vaida, BSc, PharmD, FASHP is Executive Vice President at the Institute for Safe Medication Practices (ISMP). He served as a trustee of ISMP from its incorporation as a nonprofit organization in 1994 until his employment in 2000. Dr. Vaida works closely with ISMP’s board of directors (trustees) and leadership team to carry out ISMP’s mission and vision. He is an active participant in making strategic decisions and forges new relationships to build ISMP’s visibility, impact, and financial resources.

Prior to joining ISMP, Allen served as Director of Pharmacy, Assistant Vice President, Vice President of Clinical Operations, and Chief Operating Officer at Mercy Suburban Hospital in Norristown, PA. Dr. Vaida has been an advocate of medication safety throughout his career and served as the first chair of the Center for Proper Medication Use, an organization formed under the Pennsylvania Society of Health System Pharmacists that co-sponsored the first fellowship in medication safety, in cooperation with ISMP. He served on the inaugural United States Pharmacopeia's Safe Medication Use Expert Committee from 2000 through 2005, and currently serves as a member of the US FDA Pharmacy Compounding Advisory Committee. He has also served as clinical assistant professor at the University of the Sciences in Philadelphia, adjunct assistant professor at Temple University School of Pharmacy, and adjunct associate professor for the Centers for Health Policy and Primary Care and Outcomes Research at Stanford University and Stanford University School of Medicine. He has published numerous articles and given professional presentations in the US and internationally on hospital and pharmacy systems and management, error prevention strategies, healthcare outcomes, integrated systems, and interdisciplinary collaboration. 

Dr. Vaida received a BSc in Biology from the University of Scranton, a BSc in Pharmacy from the Philadelphia College of Pharmacy and Science, and a Doctor of Pharmacy from the University of Minnesota.  In 2017 he received the Sister Gonzales Lecture Award from the Pennsylvania Society of Health-System Pharmacists.

 

Raj M. Ratwani, PHD

Director, MedStar Health National Center for Human Factors in Healthcare
Vice President of Scientific Affairs, MedStar Health Research Institute

Bio:

Raj is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at the Georgetown University School of Medicine. As director, he oversees the Center’s vision and strategy and has overall responsibility for Center activities. He is also an active applied researcher serving as principal investigator on numerous grants and contracts, including three research project grant (R01) awards from the U.S. Department of Health and Human Services (HHS), which are among the most prestigious grants. Raj has expertise in health information technology, usability and safety, interruptions and workflow, data visualization, and modeling. Raj’s research has been funded by the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), The Pew Charitable Trusts, and industry partners. His work has been published in high-impact journals such as The Journal of the American Medical Association (JAMA) and Health Affairs and has influenced both policy and frontline clinical practice. His research has been featured by PoliticoFortuneKaiser Health NewsNational Public Radio (NPR), and many other media outlets. He serves on the federal 21st Century Cures Act Health Information Technology Advisory Committee and has testified to the U.S. Senate Health, Education, Labor, and Pensions Committee. He holds a doctorate in human factors and applied cognition and was a National Research Council post-doctoral fellow at the U.S. Naval Research Laboratory.

 

Marybeth Kazanas, PharmD, BCPS, LSSGB

Director of Clinical Pharmacy Services at Medstar Health

Bio:

Marybeth Kazanas, Pharm.D., BCPS is the System Director of Clinical Pharmacy Services at MedStar Health.  In this position, Dr. Kazanas provides oversight to all entity and system clinical pharmacy programs; she also co-chairs the system Medication Safety, Antimicrobial Stewardship, and Interprofessional Continuing Education Committees; and works with site level pharmacy and physician leadership to improve drug therapy management. Prior to her current position, she has held several clinical and leadership pharmacy positions within MedStar.  Her areas of interest include medication safety, management of high cost medications and professional development.  Dr. Kazanas is actively involved with both the Maryland Society of Health-System Pharmacist and the American Society of Health-System Pharmacists.  She is currently a member of the ASHP Frontline Leaders Section Advisory Group.  She previously served as a board member for MSHP and delegate for the state of Maryland.

Dr. Kazanas obtained her Doctor of Pharmacy degree from Duquesne University, Mylan School of Pharmacy.  She then went on to complete a pharmacy practice residency at Hahnemann University Hospital in Philadelphia, PA.  She is a board-certified pharmacotherapy specialist and received her Lean Six Sigma certification from Juran.

 

Eileen Ruth Langstraat, Pharm.D., BCPS, CPPS

Pharmacy Medication and Patient Safety Coordinator

Bio:

Eileen R. Langstraat, Pharm.D., BCPS, is the pharmacy medication and patient safety coordinator at Kaiser Permanente, Rockville, Maryland. She received her bachelor of arts degree in biochemistry from Saint Mary’s College of Maryland in 2009 and her doctor of pharmacy degree from Shenandoah University in 2015. Dr. Langstraat completed an ASHP-accredited postgraduate year 1 pharmacy residency at Johns Hopkins Bayview Medical Center in 2016, where she subsequently completed a medication-use safety residency. Her current research interests include medication safety and medication-use process quality improvement.

Georgia Lewis,MSN, RN, CPNP-PC

Pediatric Nurse Practitioner 

Bio:

Georgia Lewis is a pediatric nurse practitioner focused on improving the health of underserved patients and communities as a primary care provider. She was a HRSA Nurse Corps scholarship recipient for her MSN degree at Johns Hopkins University and recently received a 2020 National Health Service Corps award. She has a background in studio art and as a labor and postpartum doula. Currently she is serving at an FQHC in the Cleveland, Ohio metropolitan area working with a predominantly Spanish-speaking immigrant population

 

Seth A. Krevat, MD

Bio:

Assistant vice president for Safety at MedStar Health and a faculty associate at MedStar Health’s National Center for Human Factors in Healthcare. In addition, he is an attending physician, Palliative Medicine, MedStar Georgetown University Hospital.

As assistant vice president for Safety, Dr. Krevat is responsible for patient and staff safety and for risk reduction programs. He focuses on understanding, coordinating, and measuring the performance of internal and external safety requirements in both the acute and non-acute care arenas. In addition, he developed and conducts a comprehensive safety program aimed at reducing safety risks and addressing serious safety events as they arise. He also leads a clinical documentation improvement program for all the MedStar hospitals.

In 2014, Dr. Krevat was selected as one of 25 physicians to participate in an 18-month MedStar leadership development program. At MedStar, he serves on several committees, including the 2020 Performance Transformation Care Management Team; the Clinical Business Council Committee; and the Quality, Safety and Risk Management Reorganization Steering Committee. He is a member of the American College of Physician Executives, the American Medical Association, and the American College of Physicians. In addition, he has presented his work at meetings of professional societies on topics such as patient safety event data and the integration of human factors engineering into patient safety and risk reduction programs. Dr. Krevat is board certified in internal medicine and in hospice and palliative medicine.

 

Misty Carney, B.S., PharmD., AAHIVP

Chief, Maryland AIDS Drug Assistance Program

Bio:

Misty Carney is from West Tennessee, Brownsville to be exact, and has been in the D.C. area for 17 years. Misty is an alumna of Tennessee State University, Howard University School of Pharmacy, and the University of Maryland School of Public Health.

Misty developed a passion for the HIV community when HIV hit close to home and she lost her uncle in the early 90’s due to lack of treatment and stigma. Consequently, her mother created the first and only community-based organization with a mobile unit geared towards education and decreasing the stigma of HIV in rural West Tennessee. The name of the organization was AIDS Resource Development Institute (ARDI) which held a vast array of events and educational platforms for those affected in Brownsville, TN and 19 counties in rural West Tennessee. Her mother’s work and dedication increased her motivation to seek a way to be just as effective in the community for PLWH through pharmacy. 

Misty is a credentialed HIV pharmacist with the American Academy of HIV Medicine and has over 10 years of experience within infectious disease and public health. She is a commissioner for the Washington DC Regional Planning Commission on Health and HIV where she is on the Community Education and Engagement Committee. Misty is also a preceptor for pharmacy students at Howard University School of Pharmacy was a preceptor in training for Walgreens Community Residency Program. Misty feels that the most rewarding part of her job is educating patients and the community in an effort to help protect and improve their health. Particularly, her passion and strengths in HIV lie with helping to improve the lives of all through education by contributing solution driven efforts within the care continuum to positively impact patient care in the Metropolitan Washington, D.C. area, and now across the state of Maryland.  

Misty Carney is from West Tennessee, Brownsville to be exact, and has been in the D.C. area for 17 years. Misty is an alumna of Tennessee State University, Howard University School of Pharmacy, and the University of Maryland School of Public Health.

Misty developed a passion for the HIV community when HIV hit close to home and she lost her uncle in the early 90’s due to lack of treatment and stigma. Consequently, her mother created the first and only community-based organization with a mobile unit geared towards education and decreasing the stigma of HIV in rural West Tennessee. The name of the organization was AIDS Resource Development Institute (ARDI) which held a vast array of events and educational platforms for those affected in Brownsville, TN and 19 counties in rural West Tennessee. Her mother’s work and dedication increased her motivation to seek a way to be just as effective in the community for PLWH through pharmacy. 

Misty is a credentialed HIV pharmacist with the American Academy of HIV Medicine and has over 10 years of experience within infectious disease and public health. She is a commissioner for the Washington DC Regional Planning Commission on Health and HIV where she is on the Community Education and Engagement Committee. Misty is also a preceptor for pharmacy students at Howard University School of Pharmacy was a preceptor in training for Walgreens Community Residency Program. Misty feels that the most rewarding part of her job is educating patients and the community in an effort to help protect and improve their health. Particularly, her passion and strengths in HIV lie with helping to improve the lives of all through education by contributing solution driven efforts within the care continuum to positively impact patient care in the Metropolitan Washington, D.C. area, and now across the state of Maryland.  

Donna Horn, MS, RPh, DPh, CHC

Pharmacy Ethics and Compliance Officer at Fresenius Medical Care North America

Bio:

Donna Horn has over 10 years experience in medication safety, 20 years experience in retail/ chain pharmacy, and over 15 years of national pharmacy regulatory experience; She wrote regulations and programs for CQI, QAP, RCA and FMEA; Masters of Science Degree in Pharmacy, concentration in Pharmaceutical Outcomes and Policy with certificate in Patient Safety and Medication Risk Management; emphasis in patient safety and ethics of drug product, distribution, and use; adjunct faculty at MCPHS Univ and guest lecturer at many colleges of pharmacy nationwide. Expert Witness for Standards of Practice in Pharmacy, including medication error analysis and wrongful death cases; extensive knowledge of medication safety practices, pharmacy operations and pharmacy regulations affecting mail-order and community/ambulatory practice sites. Experience with all boards of pharmacy: Past President of MA Board of Pharmacy, Past President and Chairman of National Association of Boards of Pharmacy; HIPAA Privacy Officer for large chain pharmacy.

Physicians 

The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The George Washington University School of Medicine and Health Sciences designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Pharmacists and Pharmacy Technicians 

The George Washington University Hospital, Department of Pharmacy is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

ACPE#: 0536-9999-20-014-H05-P
ACPE#: 0536-9999-20-014-H05-T
Release Date: October 23, 2020
Expiration Date: October 23, 2023
CE Credits: 2.00 (2.00 CEUs)

Available Credit

  • 2.00 ACPE Pharmacist
    The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
  • 2.00 ACPE Pharmacy technician
    The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
  • 2.00 AMA PRA Category 1 Credit™
    The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 2.00 Completion
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Adobe PDF File for Download:

Medication Errors.pptx