Chapter 76: Pharmacy Foundation (Med Safety!)

Question 1

What are two organizations actively involved in improving medication safety?

Answer 1

The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP)

Question 2

The formal definition of a medication error developed by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is . . .

Answer 2

“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.

Question 3

DO NOT! Confuse Med Error with ADRs why?

Answer 3

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

Question 4

Define: Close Call (NEAR MISS)

Answer 4

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)

Question 5

Define: Sentinel Event

Answer 5

Unexpected occurrence involving death
or serious physical or psychological injury to patient

Question 6

Med Error: SYSTEM-BASED CAUSES ?

Answer 6

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)

Question 7

What are some “At-Risk” Behavior that can compromise patient safety?

Answer 7

Question 8

Response - Instituations should have a plan in place for responding to med errors… the plan should include the following . . .

Answer 8

■ 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?

Question 9

Errors of Omission and Commission?

Answer 9

Question 10

Reporting of Med Error?

Answer 10

• 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.

Question 11

ORGANIZATIONS THAT SPECIALIZE IN ERROR PREVENTION

Answer 11

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.

Question 12

Evaluation and quality improvement can be performed prospectively, retrospectively or continuously. DEFINE PROSPECTIVE

Answer 12

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.

Question 13

Evaluation and quality improvement can be performed prospectively, retrospectively or continuously. DEFINE RETROSPECTIVE

Answer 13

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

Question 14

Evaluation and quality improvement can be performed prospectively, retrospectively or continuously. DEFINE CONTINOUS

Answer 14

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).

Question 15

THE JOINT COMMISSION (TJC)

Answer 15

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.

Question 16

National patient safety goals (NPSGs) are set annually by TJC for different types of healthcare settings…. list the National Patient Safety Goals

Answer 16

Question 17

COMMON METHODS TO REDUCE MEDICATION ERRORS

AVOID “DO NOT USE” ABBREVIATIONS - talk about it / what are some Do not use abb list?

Answer 17

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!

Question 18

COMMON METHODS TO REDUCE MEDICATION ERRORS

TALL MAN LETTERING - what is it?/ examples

Answer 18

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.

Question 19

COMMON METHODS TO REDUCE MEDICATION ERRORS

HIGH-ALERT MEDICATIONS: what does that mean?/ what are some ex sof high alert medications?

Answer 19

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.

Question 20

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?”

Answer 20

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

Question 21

COMMON METHODS TO REDUCE MEDICATION ERRORS

MEDICATION RECONCILIATION: what is it? describe the process/ steps, why is it important?

Answer 21

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:

1. Compile a list of current medications.
2. Create a list of medications to be prescribed.
3. Compare the two lists.
4. Identify discrepancies and make clinical decisions based on the comparison.
5. 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.

Question 22

COMMON METHODS TO REDUCE MEDICATION ERRORS

INDICATIONS AND PROPER INSTRUCTIONS ON PRESCRIPTION: why is this important/ give examples

Answer 22

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.

Question 23

COMMON METHODS TO REDUCE MEDICATION ERRORS

USE OF THE METRIC SYSTEM

Answer 23

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!

Question 24

COMMON METHODS TO REDUCE MEDICATION ERRORS

DO NOT IDENTIFY MEDICATIONS BASED ON PACKAGING ALONE

Answer 24

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.

Question 25

COMMON METHODS TO REDUCE MEDICATION ERRORS

SAFE PRACTICES FOR EMERGENCY
MEDICATIONS/ CRASH CARTS

Answer 25

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!

Question 26

COMMON METHODS TO REDUCE MEDICATION ERRORS

CHECK THE FIVE RIGHTS OF MEDICATION ADMINISTRATION

Answer 26

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.

Question 27

COMMON METHODS TO REDUCE MEDICATION ERRORS

Other Common Methods to be familar with

Answer 27

• 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

Question 28

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)?

Answer 28

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.

Question 29

USE OF TECHNOLOGY AND AUTOMATED SYSTEM

BARCODING

Answer 29

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.

Question 30

USE OF TECHNOLOGY AND AUTOMATED SYSTEM

AUTOMATED DISPENSING CABINETS: Common names of ADCs are

Answer 30

Pyxis, Omnicell, ScriptPro and AccuDose

Question 31

Practical Benefits of ADCs

Answer 31

Drug inventory and medication replenishment can be automated when drugs are placed into cabinet and removed. ADCs provide enhanced security of controlled drugs by recording detailed info about transcation!

Question 32

Methods to Improve ADC Safety

Answer 32

• The Joint Commission (TJC) mandates pharmacist review of orders before medication removal from ADCs, except in emergencies, with all overrides requiring investigation.
• Common ADC errors include wrong drug/dose administration; practitioners accessing the patient’s MAR during medication retrieval can mitigate errors, and barcode scanning enhances safety.
• Look-alike, sound-alike medications should be stored separately within ADCs.
• Certain medications like insulin, warfarin, and high-dose narcotics (hydromorphone 10 mg/mL and morphine 20 mg/mL) should not be stocked in ADCs.
• Nurses should not return medications to the compartment; a separate drawer for returned medications is recommended.
• Environmental factors such as noise, lighting, and workload can contribute to errors when using ADCs.

Question 33

PATIENT CONTROLLED ANALGESIA DEVICES: What is it? / how can it benefit patients?

Answer 33

Opioids effectively manage moderate to severe post-surgical pain and can be administered via Patient-Controlled Analgesia (PCA) devices. With PCA, patients self-administer medication doses by pushing a button, ordered by the physician, preventing overdoses. PCAs enable quick pain relief without nurse intervention, reduce side effects by allowing small doses, and closely mimic pain patterns for better control. PCAs are increasingly combined with anesthetics for synergistic pain relief.

Question 34

PCA Safety Considerations

Answer 34

• PCA devices are complex and prone to errors during setup and programming, contributing significantly to preventable medication errors. Therefore, they should only be used by well-coordinated healthcare teams.
• Patients must be suitable candidates for PCA treatment, requiring cooperation and cognitive assessment to ensure they can follow instructions.
• It is a requirement by The Joint Commission (TJC) that friends and family members should not administer PCA doses.
• While respiratory depression is not common with PCAs, the risk is present.

Question 35

PCA Safety Steps

Answer 35

• Limit opioids available outside of ADCs and utilize standard order sets, especially for opioid-naive patients, to ensure safe drug dosages.
• Educate staff about the differences between HYDROmorphone and morphine to prevent mix-ups.
• Implement PCA protocols with independent double-checking of drug, pump settings, and dosage, ensuring MAR concentration matches PCA label.
• Utilize barcoding technology, where available, to ensure correct concentration during PCA programming and patient verification.
• Schedule regular assessments of patients’ pain, sedation, and respiratory rate.

Question 36

COMMON TYPES OF HOSPITAL-ACQUIRED (NOSOCOMIAL) INFECTIONS

Answer 36

■ Urinary tract infections from indwelling catheters (very common). Remove the catheter as soon as possible.
■ Blood stream infections from IV lines (central lines have the highest risk) and catheters
■ Surgical site infections
■ Decubitus ulcers
■ Hepatitis
■ Clostridium (clostridioides) difficile, other GI infections
■ Pneumonia (mostly due to ventilator use)

Question 37

Universal Precautions To Prevent Transmission…Universal precautions involve treating all human blood and bodily fluids as potentially infectious for diseases like HIV and HBV. Good hand hygiene is essential, and in certain situations, gowns, masks, or patient isolation may be necessary to prevent contact with bodily fluids. The CDC defines three categories of transmission-based precautions. defined by the CDC:

Answer 37

Contact Precaution, Droplet Precaution, Airborne Precaution

Question 38

Contact Precautions: Purpose and steps?

Answer 38

• Aimed at preventing transmission of infectious agents through direct and indirect contact with patients and their environment.
• Preferably, patients are placed in single rooms; if unavailable, maintain approximately +3 feet of spatial separation between beds to avoid item sharing between patients.
• Healthcare personnel caring for these patients should wear gowns and gloves for all interactions involving contact with the patient or contaminated areas.
• Contact precautions are advised for patients with MRSA, VRE colonization or infection, and those with C. difficile infection.

Question 39

Droplet Precaution: Purpose and steps?

Answer 39

• Aimed at preventing transmission of pathogens spread through close respiratory contact with respiratory secretions.
• Single patient rooms are preferred; if unavailable, maintain approximately 3 feet spatial separation and draw a curtain between beds, particularly for diseases transmitted via droplets.
• Healthcare personnel should wear a mask during close contact with the patient, donning it upon entry to the patient’s room.
• Droplet precautions are advised for patients with active B. pertussis, influenza virus, respiratory syncytial virus (RSV), adenovirus, rhinovirus, N. meningitidis, and group A streptococcus (for the first 24 hours of antimicrobial therapy).

Question 40

Airborne Precaution: Purpose and steps?

Answer 40

• Aimed at preventing transmission of infectious agents that remain infectious over long distances when suspended in the air.
• Patients should be placed in an airborne infection isolation room (AIIR), equipped with special air and ventilation handling systems.
• Healthcare personnel should wear a mask or respirator (N95 level or higher), depending on the disease, prior to room entry.
• Airborne precautions are advised for patients with active pulmonary tuberculosis, measles, or varicella virus (chickenpox).

Question 41

CATHETER-RELATED BLOODSTREAM
INFECTIONS: What are some key strategies for minimizing catheter-related bloodstream infections (CRBSI), and how can healthcare professionals balance the effectiveness of these strategies with potential risks, such as antibiotic resistance?

Answer 41

• Aseptic technique during catheter insertion, including proper handwashing and adherence to standard protocols/checklists, is the most important and cost-effective strategy to minimize catheter-related bloodstream infections (CRBSI).
• Minimizing the use of intravascular catheters is crucial, where possible, by implementing intravenous to oral route protocols and setting appropriate time limits for catheter use. For instance, peripheral catheters should be replaced every 2 - 3 days to reduce infection risk.
• Additional strategies to reduce CRBSI risk include using skin antiseptics like 2% chlorhexidine, antibiotic-impregnated central venous catheters, and antibiotic/ethanol lock therapy. However, these methods must be carefully evaluated for potential risks of increased resistance.

Question 42

HAND HYGIENE: general info

Answer 42

Proper hand hygiene in healthcare settings significantly reduces nosocomial infections. Alcohol-based hand rubs are more effective than plain soap, though soap and water are suitable in certain situations. Short nails and no jewelry under gloves minimize bacterial harboring and glove tearing. Antimicrobial hand soaps with chlorhexidine or triclosan may be preferable for infection control in healthcare facilities.

Question 43

When to Perform Hand Hygiene?

Answer 43

■ Before entering and after leaving patient rooms and
between patient contacts if there is more than one patient per room.
■ Before donning and after removing gloves (use new gloves with each patient).
■ Before handling invasive devices, including injections.
■ After coughing or sneezing.
■ Before handling food and oral medications.

Question 44

Use Soap and Water (not Alcohol-Based Rubs) in These Situations

Answer 44

■ Before eating.
■ After using the rest room.
■ Anytime there is visible soil (anything noticeable on the hands).
■ After caring for a patient with diarrhea or known C. difficile or spore-forming organisms; alcohol-based hand rubs have poor activity against spores. Handwashing physically removes spores.
■ Before caring for patients with food allergies.

Question 45

Soap and Water Technique and Alcohol based hand rub technique

Answer 45

Soap and Water Technique
■ Wet both sides of hands, apply soap, rub together for at least 15 seconds.
■ Rinse thoroughly.
■ Dry with paper towel and use the towel to turn off the water.
Alcohol based hand rub technique
■ Use enough gel (2- 5 mL or about the size of a quarter).
■ Rub hands together until the rub dries (15- 25 seconds).
■ Hands should be completely dry before putting on gloves

Question 46

Safe Injection Practices for Healthcare Facilities

Answer 46

Question 47

What are the recommended procedures and guidelines for the safe disposal of needles and sharps used by patients receiving injectable medications?

Answer 47

Patients using injectable medications should immediately dispose of needles and sharps in FDA-cleared sharps containers. These containers should be puncture-resistant, appropriately labeled or color-coded, and leak-proof. They should be marked with a line that indicates when container is considered full (about 3/4 full). Avoid compressing or pushing down on the contents of the container.

If an FDA-cleared container is unavailable, some community guidelines suggest using a heavy-duty plastic household container as an alternative, such as a plastic laundry detergent container. This container must also be leak and puncture-resistant with a tightly fitting lid.

The entire needle/syringe assembly should be discarded. Recapping a needle is only permitted when a sharps container is not immediately available. In such cases, the one-hand method should be used to recap until a sharps container can be reached. This involves (1) placing the cap on table or counter next to something firm to push cap against, (2) Hold the syringe with the needle attached and slip the needle into the cap without using the other hand

Disposal guidelines and programs vary, and local trash removal services or health departments typically provide information on available services. These services may include drop boxes, supervised collection sites (e.g., hospitals, pharmacies, police or fire stations), household hazardous waste collection sites, mail-back programs, and residential special waste services pick-up. Pharmacies can assist patients by providing disposal information.

Question 48

Medication Use Process

Errors can occur at any point in the medication use process. Multiple layers of safey checks (aka Swiss cheese model) help to reduce the risl of error reaching the patient
TALK ABOUT THE INPATIENT MEDICATION USE PROCESS

Answer 48

Question 49

Medication Use Process

Errors can occur at any point in the medication use process. Multiple layers of safey checks (aka Swiss cheese model) help to reduce the risl of error reaching the patient
TALK ABOUT THE OUTPATIENT MEDICATION USE PROCESS

Answer 49