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exposures to detect an adverse reaction—particularly reactions that occur with low frequencies. According to the U.S. Food and Drug Administration (FDA) learning module, “Preventable Adverse Drug Reactions: A Focus on Drug Interactions,” most drugs are approved for use by the FDA with an average of only 1,500 patient exposures and tested for relatively short period of time. A few million patients make take a new drug before the low-frequency adverse reactions are identified. For drugs that cause rare toxicity, the toxicity will only be detected after use by many more thousands of patients (FDA, 2014). Specific Preventive Measures Naming, Labeling, Packaging, and Abbreviations The FDA has a seven-part role in reducing and preventing medication errors: Drug name review. To minimize confusion between drug names that look or sound alike, the FDA reviews about 400 brand names a year before they are marketed, and about one-third are rejected. Drug labels. Over-the-counter (OTC) medications require “standardized drug facts labels” and improved inserts in prescription medications for healthcare professionals. Drug labeling and packaging. Works with drug companies to reduce problems stemming from labels and packages that are similar to one another or show poor product design. Bar code label rule. Since 2004 certain drugs and biologics must have bar codes as part of their labels. When used with scanners and computerized patient information systems these help ensure the right dose of the right drug is given to the right patient at the right time.Error analyses. Reviews about 1,400 reports of med errors every month. Guidances for industry. Three new guidance statements are being reviewed regarding trade name development, pitfalls of drug labeling, and best test practices for drug naming. Public education. Helps educate the public through various models about preventing medical errors. (FDA, 2009) In 2006 the FDA and Institute for Safe Medication Practices (ISMP) have launched a national education campaign to eliminate the use of ambiguous medical abbreviations that are frequently misinterpreted and lead to mistakes resulting in patient harm. The campaign seeks to promote safe practices among those who communicate medical information (FDA, 2006). The FDA recommends that clinicians review the Institute for Safe Medical Practices’ List of Error-Prone Abbreviations, Symbols and Dose Designation as shown in the following tables. **These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this Joint Commission requirement.Source: Institute for Safe Medical Practices (ISMP), 2015. The Public Health Practice Unit (PHPU) is pleased to be able to provide this training with a continuing education opportunity. This is a self-paced course which means that once the course is completed with an 80% or higher on the post assessment and the evaluation is completed and submitted back to the Public Health Practice Unit, continuing education credit will be turned in to CE Broker on the participant’s behalf. In order to receive continuing education credit, the participant must complete the Evaluation Form (completed with participant’s name as it appears on the license and license number) attached to this course and return the form by fax (850-922-0462) or email. Slide 2 Slide 2 – How to Use Navigation In order to make your training experience as easy as possible during the course of this self-paced Training Course, we are providing these navigation instructions. When a slide pauses you can do one of three things to advance the presentation: You may click directly on the slide with your cursor; You may click on the PLAY button on the bottom left of the screen; or you may click on the FORWARD button, also located on the bottom left of the screen. 13 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide If you need to review a previous slide, you may click the BACK button on the bottom left of the screen. Please keep these instructions in mind as you proceed with this training. You will need to advance the slide now. Slide 3 The Office of Performance and Quality Improvement, Public Health Practice Unit is an approved provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing, Florida Board of Accreditation #NCE 50-712. Meets requirement of 2 hours CE. As a Florida Board of Nursing approved provider of nursing continuing education, this course meets the Florida requirement for 2 hours of continuing education on prevention of medical errors for initial licensure and biennial renewal according to Florida Statute 456.013. This course addresses the impact of medical errors on today’s healthcare system with a focus on the outpatient setting, root cause analysis, error reduction and patient safety. It further addresses medical errors that are relevant to the public health environment. Information and research informing the content of this program has been derived from historical reports authored or published by the Institute of Medicine as well as scholarly literature review. 14 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 4 LEARNING OBJECTIVES Upon completion of this course, you will be able to: ‒ Identify the scope of the problem ‒ List factors that increase the risk of medical errors ‒ Recommend general process changes which reduce errors and improve patient safety ‒ Discuss evidence-bases strategies to decrease risk of medical errors Continued… Following completion of this course, it is expected that the participant will be able to: • Identify the extent to which medical errors occur in the healthcare system; • List factors that increase the risk of medical errors; • Recommend process changes which reduce risk of errors; • Discuss evidence-based strategies for reducing the risk of medical errors; Slide 5 LEARNING OBJECTIVES Upon completion of this course, you will be able to: ‒ Summarize internal and external reporting responsibilities ‒ Describe the importance of communication in the prevention and identification of medical errors. ‒ Explain the role of root cause analysis in prevention of recurrence of medical errors. • Summarize internal and external reporting responsibility; • Describe the importance of communication in preventing and identifying medical errors; and • Explain the importance and role of root cause analysis in prevention and recurrence of medical errors. The Public Health Practice Unit offers definitions for various words and technical verbiage which the participant will see throughout the presentation and may want to reference at a later date. Definitions have been derived from historical reports authored or published by the Institute of Medicine. Adverse event-an injury resulting from a medical intervention rather than the underlying medical condition of the patient. It is considered preventable and signals the need to ask why the error occurred. Medical error - The failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems. Near miss - “Any potentially harmful event that could have had an adverse result but, through chance or intervention in which, harm was prevented.” [§381.0271(7a.3), FS] Slide 7 DEFINITIONS Preventable harm - an adverse occurrence or event which results from insufficient vigilance or lack of prudence or forethought on the part of individual providers Safety of care - freedom from accidental injury Sentinel event - an unexpected occurrence involving death, serious physical harm or psychological injury or risk thereof. Preventable harm - An adverse occurrence or event which results from insufficient vigilance or lack of prudence or