Chapter 76: Pharmacy Foundation Med Safety & PK Flashcards
What are two organizations actively involved in improving medication safety?
The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP)
The formal definition of a medication error developed by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is . . .
“any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”
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Ex: This can include errors made in prescribing, order communication, product labeling and packaging, compounding, dispensing, administration, education and monitoring.
DO NOT! Confuse Med Error with ADRs why?
ADRs are usually not avoidable, although they may be likely to occur if the drug is given to a patient at high-risk for certain
complications
Define: Close Call (NEAR MISS)
When an error or situation occurred but was corrected before reaching patient (eg. inappropriate dose ordered but pharmacist identified error and contacted prescriber to correct dose prior to order verification)
Define: Sentinel Event
Unexpected occurrence involving death
or serious physical or psychological injury to patient
Med Error: SYSTEM-BASED CAUSES ?
Experts in medication safety agree that the most common cause of medication errors is a problem with the design of the medical system itself, not usually an individual making an
error. Instead of placing blame on individual, healthcare professionals should find ways to improve the system (referred to as Just Culture)
What are some “At-Risk” Behavior that can compromise patient safety?
Response - Instituations should have a plan in place for responding to med errors… the plan should include the following . . .
■ Internal notification: who should be notified within the institution and within what time frame?
■ External reporting: who should be notified outside of the institution?
■ Disclosure: what information should be shared with the patient/family? Who will be present when this occurs?
■ Investigation: what is the process for immediate and longterm internal investigation of an error?
■ Improvement: what process will ensure that immediateand long-term preventative actions are taken?
Errors of Omission and Commission?
Reporting of Med Error?
- Medication errors, adverse drug reactions, and near misses should be reported to prevent future occurrences.
- Reporting allows for systemic changes to enhance safety measures. In pharmacies, staff member who discovers error should immediately report to appropariate established channels / to the appropriate office. State boards of pharmacy often mandate quality assurance programs to prevent errors.
- Error Investigations should occur swiftly (within 48 hrs of incident) to maintain clarity. Reporting errors to patients and prescribers is an ethical obligation. Hospitals typically use electronic reporting systems, though some still utilize paper systems. Committees like Pharmacy and Therapeutics and Medication Safety should be informed of errors.
ORGANIZATIONS THAT SPECIALIZE IN ERROR PREVENTION
The ISMP National Medication Errors Reporting Program (MERP) provides a confidential, voluntary platform for reporting medication errors and close calls. It offers expert analysis to identify systemic causes and recommend prevention strategies. Professionals and consumers are encouraged to report errors on the ISMP website, even if already reported internally. Manufacturers may be prompted to enhance safety measures in response to frequent reports of a specific error, such as implementing REMS programs or making changes to names or packaging. Pharmacists should prioritize reading medication error reports, such as ISMP’s safety alerts, and share insights with their team to improve safety practices.
Evaluation and quality improvement can be performed prospectively, retrospectively or continuously. DEFINE PROSPECTIVE
Failure mode and effects analysis (FMEA) is a proactive approach to reduce frequency and consequences of errors. It evaluates system design to anticipate potential failures and assesses the impact of changes to medication delivery systems or new drugs added to the formulary.
Evaluation and quality improvement can be performed prospectively, retrospectively or continuously. DEFINE RETROSPECTIVE
A root cause analysis (RCA) is a retrospective
investigation of an event that has already occurred,
which includes reviewing the sequence of events
that led to the error…analysis hopes to prevent future error
Evaluation and quality improvement can be performed prospectively, retrospectively or continuously. DEFINE CONTINOUS
Continuous quality improvement (CQI) is a primary objective in healthcare, enhancing efficiency, quality, and patient satisfaction while cutting costs. Lean and Six Sigma, often combined, are prominent CQI methodologies. Lean targets waste reduction, while Six Sigma concentrates on defect minimization through the DMAIC process (define, measure, analyze, improve, control).
THE JOINT COMMISSION (TJC)
TJC is an independent, not-for-profit organization that accredits and certifies more than 17,000 healthcare organizations and programs in the U.S., including hospitals, healthcare networks, long-term care facilities, home care organizations, office-based surgery centers and independent laboratories.
TJC emphasizes top-quality and safe care, establishing accreditation standards for institutions. Accredited organizations must undergo on-site surveys every three years, sometimes unannounced.
National patient safety goals (NPSGs) are set annually by TJC for different types of healthcare settings…. list the National Patient Safety Goals
COMMON METHODS TO REDUCE MEDICATION ERRORS
AVOID “DO NOT USE” ABBREVIATIONS - talk about it / what are some Do not use abb list?
Abbreviations are unsafe and contribute to many medical error. The minimum list of “Do Not Use” abbreviations per TJC is shown in the table pic. ISMP also publishes a list of errorprone abbreviations, symbols and dosage designations which includes those on TJC’s list and many others!
COMMON METHODS TO REDUCE MEDICATION ERRORS
TALL MAN LETTERING - what is it?/ examples
Look-alike, sound-alike medications are a common cause of medication errors. Poor handwriting and similar product labeling aggravate the problem. Drugs that are easily mixed up should be labeled with tall man letters. Here are two examples:
■ CeleXA, CeleBREX
■ predniSONE, prednisoLONE
Using tall man letters, which mix upper and lower case letters, draws attention to the dissimilarities in the drug names. Safety-conscious organizations (e.g., ISMP, FDA, TJC) have promoted the use of tall man letters!
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Drug dictionaries in computer systems and automated dispensing cabinets (ADCs) feature alerts to confirm accurate medication orders or withdrawals. For instance, a warning might appear asking if the provider intended to select “hydroMORPHONE” instead of “DILAUDID” to prevent confusion with morphine.
COMMON METHODS TO REDUCE MEDICATION ERRORS
HIGH-ALERT MEDICATIONS: what does that mean?/ what are some ex sof high alert medications?
Drugs with a heightened risk of causing significant patient harm if used in error, should be designated as high-alert. High-alert medications can be used safely through protocols or order sets, prioritizing premixed products, limiting available concentrations, and stocking them only in the pharmacy. Such protocols enhance appropriate prescribing and decrease errors from inappropriate use.
COMMON METHODS TO REDUCE MEDICATION ERRORS
Utilization of Medication Therapy Management: What are the key components and benefits of Medication Therapy Management (MTM), and how does it facilitate collaboration between pharmacists, patients, and prescribers to address treatment gaps, improve adherence, and identify cost-saving opportunities?”
Medication Therapy Management (MTM) helps uncover errors during Medication Therapy Reviews (MTR). It involves creating a Personal Medication Record (PMR) and a Medication-Related Action Plan (MAP), often led by pharmacists. Following this, interventions, referrals, documentation, and follow-up plans are implemented. MTM focuses on patients with multiple chronic conditions and medications, using computer databases to identify high-risk individuals.
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Pharmacists collaborate with patients and prescribers to address treatment gaps, such as missing medications like ACE inhibitors for diabetic patients with albuminuria, or beta-blockers post-heart attack. They use Medication Therapy Management (MTM) to tackle nonadherence in heart failure patients, reducing emergency visits. Additionally, MTM identifies cost-saving opportunities by recommending generics, affordable brands, or patient assistance programs
COMMON METHODS TO REDUCE MEDICATION ERRORS
MEDICATION RECONCILIATION: what is it? describe the process/ steps, why is it important?
Medication reconciliation is the process of comparing a patient’s new medication orders with all current medications taken at home, including OTC and supplements, to prevent errors like omissions, duplications, dosing errors, or drug interactions during ToC.
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Medication reconciliation should occur during every ToC involving new or rewritten medication orders. These transitions include changes in setting, service, practitioner, or level of care, such as hospital admission, transfer, or discharge. The process involves five steps:
- Compile a list of current medications.
- Create a list of medications to be prescribed.
- Compare the two lists.
- Identify discrepancies and make clinical decisions based on the comparison.
- Communicate the updated list to caregivers and the patient.
During discharge, medication reconciliation allows the prescriber to review home medications previously on hold and determine which hospital medications should continue post-discharge.
COMMON METHODS TO REDUCE MEDICATION ERRORS
INDICATIONS AND PROPER INSTRUCTIONS ON PRESCRIPTION: why is this important/ give examples
Clear indications on prescriptions, like “lisinopril 10 mg once daily for hypertension,” aid pharmacists in ensuring appropriate drug selection. It’s recommended to avoid using “as directed” because it lacks clarity for patient and complicates verification of dosing. While “as directed” may be used with a separate dosing calendar, such as with warfarin, it’s preferable to write “use per instructions on the dosing calendar” to ensure patient understanding and awareness of additional instructions.
COMMON METHODS TO REDUCE MEDICATION ERRORS
USE OF THE METRIC SYSTEM
Measurements should be recorded using metric system only! Prescribers shoul use metric units to epress all weights (g or kg) and olume (ml or L). Additionally, standard use of ml over tsp. is preferred!
COMMON METHODS TO REDUCE MEDICATION ERRORS
DO NOT IDENTIFY MEDICATIONS BASED ON PACKAGING ALONE
Look-alike packaging can lead to errors. To mitigate this risk, separate similar-looking drugs in both the pharmacy and patient care units, or consider repackaging them. Never solely rely on packaging apperance (eg. color, design) to identify the correct drug product.
COMMON METHODS TO REDUCE MEDICATION ERRORS
SAFE PRACTICES FOR EMERGENCY
MEDICATIONS/ CRASH CARTS
The medications should be unit dose
(e.g., the package contains a single dose) and age-specific, including pediatric-specific doses. If unit dose not available, prefilled synringes are next best. A standardized drug reference sheet should be availoable during emergencies (eg. Broselow tape for peds)
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Ex. Code Blue - A code blue refers to a patient requiring emergency medical, typically cardiac or respiratory arrest. During the code, closed loop communication (repeating back for verification) is used!
COMMON METHODS TO REDUCE MEDICATION ERRORS
CHECK THE FIVE RIGHTS OF MEDICATION ADMINISTRATION
The “five rights” are essential safety checks that healthcare professionals should perform before administering medication. While they’re a best practice, they should be complemented/ combine with other system-based error prevention methods. Ex. Barcoding is a technological tool that aids in ensuring the “five rights” during medication administration.
COMMON METHODS TO REDUCE MEDICATION ERRORS
Other Common Methods to be familar with
- DEDICATE PHARMACISTS TO HIGH-RISK AREAS The intensive care unit (ICU), pediatric units and EDs
- MONITOR FOR DRUG-FOOD INTERACTIONS
- EDUCATION: Staff education programs, or “in-services,” are crucial for introducing new high-alert drugs, procedural changes, and guidelines to prevent medication errors in healthcare facilities. Written medication information should be at an appropriate reading level for patients, with additional support provided, such as pictures or translation services, for those who do not speak or read English.
- USE INTERDISCIPLINARY TEAMS! gives us different background/ idea… a collaborative practice agreement between physicans/pharmacist allows pharmacist to provide specific services
USE OF TECHNOLOGY AND AUTOMATED SYSTEM
How does Computerized Physician/Provider Order Entry (CPOE) enhance patient safety, particularly when combined with Clinical Decision Support (CDS)?
Computerized Physician/Provider Order Entry (CPOE) allows prescribers to directly enter medical orders, reducing errors associated with handwritten orders. Combining CPOE with Clinical Decision Support (CDS) tools enhances patient safety by incorporating clinical guidelines and patient labs into the system. Alerts notify prescribers of inappropriate drug choices or potential safety concerns based on patient-specific data.
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CPOE can include standard order sets, clinical decision pathways and protocol.
USE OF TECHNOLOGY AND AUTOMATED SYSTEM
BARCODING
Barcoding is considered one of the most crucial tools in reducing medication errors.
The barcode system helps in accurately tracking medications from the time they are stocked in the pharmacy to the point of administration to the patient. This ensures that medications are stored in the correct location within the pharmacy and dispensed from the right pocket in the dispensing cabinet. During the compounding process, barcoding helps to verify that the correct ingredients and doses.
At the bedside, barcodes are used to confirm that the correct medication is being administered to the right patient. This is done by scanning the barcode on the drug’s packaging and matching it with the barcode on the patient’s wristband.
Barcoding also helps to prevent the diversion of drugs that are commonly abused. By having barcodes on medication packaging, it becomes easier to track the movement of these drugs.
Barcodes are now commonly found on infusion pumps as well. This technology helps to prevent errors related to medications being given intravenously. It can identify drugs that are not meant to be administered via this route and auto-program infusion parameters from the EMR, reducing the risk of manual input errors.