Transcript PowerPoint-presentatie

Introduction
Dr. Frans van de Vaart
KNMP – The Netherlands
Primum Non Nocere
First, do no harm.
In Dubio Abstine
In doubt, do not intervene.
• Drug licensing
• Manufacturer licensing
• GMP
• Risk management programs
• Pharmacovigilance
HARM (2006)
Patricia van den Bemt
Toine Egberts
Anne Leendertse
• 5.6% (40.000) of all hospital
admissions are related to
medication
• almost 50% are potentially
preventable
• 1200 deaths ...
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Establishing a national focus to create
leadership, research, tools, and protocols
to enhance the knowledge base about
safety.
Identifying and learning from errors by
developing a nationwide public
mandatory reporting system and by
encouraging health care organizations
and practitioners to develop and
participate in voluntary reporting
systems.
Raising performance standards and
expectations for improvements in safety
through the actions of oversight
organizations, professional groups, and
group purchasers of health care.
Implementing safety systems in health
care organizations to ensure safe
practices at the delivery level.
HARM Wrestling (2009)
Peter de Smet et al.
40 recommendations to prevent
hospital admissions related to
medication
http://www.knmp.nl/downloads/medicijnenzorgverlening/medicatieveiligheid/harmwrestling
EnglishcopyrightKNMP.pdf
HIGH
RISK
PATIENT
HIGH
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PROCESS
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DRUG(S)
Drug related problems HIGH
during hospital stay
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PATIENT
Anticoagulants
Antibiotics
NSAIDs/ASA
NaCl/other infusion fluids
Chemotherapy
Opiates/analgesics
HIGH
Contrast agents
RISK
PROCESS
Diuretics
Insulins
HIGH
RISK
DRUG(S)
HIGH
HIGH
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PATIENT
PATIENT
HIGH
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PROCESS
HIGH
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PROCESS
HIGH
HIGH
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PATIENT
PATIENT
HIGH
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PROCESS
HIGH
RISK
DRUG(S)
HIGH
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PATIENT
HIGH
RISK AREA
HIGH
RISK
PROCESS
HIGH
RISK
DRUG(S)