Medication Incidents Part 1: CQI

Question 1

what is the definition of continuous quality improvement (CQI)?

Answer 1

a structured organizational process for involving personnel in planning & executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations

Question 2

The Canadian incident analysis framework asks what 4 questions when an incident occurs?

Answer 2

1. what happened?
2. how and why did it happen?
3. How do we reduce the likelihood of it happening again?
4. what was learned?

Question 3

what is a root cause analysis?

Answer 3

a process used to determine the underlying causes of an event and identify strategies to prevent them in the future

Question 4

an ____ analysis is based on the premise that each human error has a preceding cause

Answer 4

root cause

Question 5

what are 3 types of diagrams that can be used to demonstrate an root cause analysis?

Answer 5

1. fishbone
2. tree diagram
3. constellation diagram

Question 6

what are the 4 stages of implementing change?

Answer 6

plan, do, study, act

Question 7

what are the 3 goals of medication safety self assessment?

Answer 7

1. raise awareness of specific characteristics of a safe medication system
2. be used as a QA tool
3. create a baseline and ability to evaluate and monitor efforts over time s

Question 8

a ____ analysis is a step-by-step approach to identifying all possible failures in a service

Answer 8

failure mode and effects analysis (FMEA)

Question 9

what is a failure mode?

Answer 9

the ways or mode in which something might fail

Question 10

what are the 3 goals of a FMEA?

Answer 10

1. eliminate failures before they happen
2. make failures visible so they wont reach patients
3. reduce impact of a failure if it does reach a patient

Question 11

t/f FMEA is pat of the accreditation for Canadian hospitals and has applications in community pharmacy as well

Answer 11

t

Question 12

what are the 3 categories for evaluating failure modes in a FMEA?

Answer 12

1. severity: how bad would it be?
2. occurrence: how often does it happen?
3. Detectability: How easily do we notice it?

Question 13

what is a cognitive walkthrough?

Answer 13

involves physically walking through the process or task of interest and examining the mental activities required at each step and the ways something could go wrong