Building a Safe Medication Management System

Question 1

what does a sentinel event trigger

Answer 1

a root cause analysis by the JC

Question 2

FDA

Answer 2

dictate safety and efficacy for intended use, dispensing

Question 3

state laws regulate

Answer 3

pharmacists

Question 4

DOPL

Answer 4

licensing, should not steal med pad

Question 5

to err is human highlighted

Answer 5

med error

Question 6

leapfrog

Answer 6

ceo leverage influence to advance pt safety in medication

Question 7

JC included med error in

Answer 7

NPSG

Question 8

tracer methology

Answer 8

JC chooses pt to follow from admission and discharge, what happens

Question 9

many ADEs are

Answer 9

preventable

Question 10

antibiotics are

Answer 10

overprescribed, pt expect to leave clinic with prescription

talk w pt that med is not needed

Question 11

med error

Answer 11

no uniform definition
any preventable event that can lead to pt harm

Question 12

medication w/o harm

Answer 12

aim to reduce severe avoidable mediciation errors

Question 13

reconciliation

Answer 13

what med did pt come in with, and what med they leave with

Question 14

most proximal error of medication usage?

Answer 14

lack of knowledge about the drug

Question 15

ADE

Answer 15

error of omission (didn’t give) or commission

Question 16

transition of care

Answer 16

well documented source of preventable harm

Question 17

types of med errors

Answer 17

admin error - incorrect route of admin, wrong dose/pt

monitoring error - failing to consider pt entire condition, allergy, or potential drug combo interaction

compliance error - not following protocol for dispensing medication

Question 18

common sys failures include

Answer 18

inaccurate order transcription
drug knowledge dissemination
failing to obtain allergy history
poor communication
unavailable medication

Question 19

where to report drugs

Answer 19

FDA MedWatchA

Question 20

AHRQ strategies to prevent ADES

Answer 20

prescribing - be conservative
transcribing- on the decline, mostly electronic
dispensing - avoiding mistaking med for each other
administration - barcode, minimize interruption

Question 21

performance tracking - PDMP

Answer 21

pharmacies can tell if pt is getting med from other doctors/pharmacies, avoid exploitation

Question 22

PQA- pharmacy quality alliance

Answer 22

track information on med safety, adherence, use

Question 23

CMS star rating programs- high stakes

Answer 23

reimbursement tied to performance on quality metrics

Question 24

pharmacists

Answer 24

dispensing role in HC,

Question 25

MTM focuses on

Answer 25

Medication therapy review  Pharmacotherapy consults  Anticoagulation management  Immunizations  Heath and wellness programs

Question 26

med errors are reported

Answer 26

voluntarily, so underreported

Question 27

risk factors that cause adverse med errors

Answer 27

work is busy, lack of literacy, many med similarities

Question 28

med management

Answer 28

prep and dispense med amin med monitor med effects states are required to monitor drug usage for medicaid pts

Question 29

step 1- select and procure medication

Answer 29

maintain formulary annually (safe and effective) (inventory of all their common medications)

Question 30

if you bring med to hospital

Answer 30

give it to them, so they can track it

Question 31

drug pedigree

Answer 31

chain of custody of drug from manufacturer to pharmacy

Question 32

step 2: properly store med

Answer 32

prevent unauthorized access, double locked sotrage

Question 33

step 3: prescribe and transcribe med

Answer 33

acceptable use of verbal orders, read back- ensure you heard the order correctly can't use abbreviations when ordering certain med- JC

Question 34

step 4: dispense med

Answer 34

pharmacist review each prescription or med order for appropriateness prevent prescribing, admin, and pharmacy errors standardized labeling keep in package until admin

Question 35

step 5 admin med

Answer 35

two pt identifier prior admin, unit dose sys, six rights

Question 36

six rights of med admin

Answer 36

Right patient  Right medication  Right dose  Right time  Right route  Right documentation  + Right to Refuse

Question 37

step 6- monitor med effects

Answer 37

monitor first dose of med, gather pt perceptions, process in place to deal with Ade

Question 38

step 7: evaluate med manage sys

Answer 38

analyze med error or near misses with committee

Question 39

drug diversion

Answer 39

removal of med from its usual stream of prep, dispensing, and admin by personnel involved in those steps to sell med in nonhealthcare setting

Question 40

drug diversion results in

Answer 40

outbreak of ID, increased ED visits, death, avoidable expenditures, lost productivity

Question 41

FMEA- failure mode and effect analysis

Answer 41

proactive tool to analyze potential problems when introducing new sys or exiting process, includes defining high risk process using flow charts freq of failure potential harm likelihood failure will be detected before it reaches pt