Dispensing and Medication Safety Flashcards
(17 cards)
Why is medical error a concerning issue?
- Medical errors cause death in Individuals.
- WHO estimates medication errors result in 1 death in every million patients and harm to at least 1.5 million people every year.
- Estimated medical error is the third most common cause of death behind heart disease in the US
Define medication safety
The freedom from accidental injury due to medical care or medical errors during the medication-use process.
Whats the definition of blame culture and list the consequences
- Define: Views individual as the cause for errors. Does not create a safe working envvironment.
- Consequences:
- Staff may be continuously stressed about making mistakes
- Staff may become traumatized if mistakes occur
- Staff may hide errors and so less error reporting
= [as a result] no one learns from mistakes and mistakes are repeated
What is the system theory? Also list the pros and cons.
- Define: systems are a cause of error
- Swiss cheese model is used to explain the system theory
- Says that with every process we are engaging in the pharmacy there are hazards at one end and losses at the other end
- System-based strategies are lined up to prevent dangerous consequences (i.e. giving the wrong medication to the patient, giving the med to the wrong patient)
E.g. of system-based strategies: computer generated prescriptions, barcode scanner, double check from pharmacist, confirm patient name - Benefit: Creates a blame-free culture: immunity for reporting errors, better error reporting (keep error reports internal)
- Cons: decreased accountability
What is Just Culture?
Aim: create open and fair system that encourages learning. It recognises the roles of system in error and creating systems to reduce errors but still being responsible for the items the pharmacist dispense
Outline the key processes involved in Just Culture?
-
Develop safer systems (by: identifying risks, reporting and learning from near misses and errors, making a safe choice)
2.** Never take a shortcut:** dont sign of something that wasn’t done - Take an extra moment and check if your not sure
How are medication errors reported in pharmacy practise? Why is this necessary?
- NSW Health Incident Management System (IMS+)
- PDL reporting
* Determines how the error was made and to put strategies in place to prevent these
Outline look alike, sound alike (LASA) medications
A key cause of medication errors
Errors are made because medicines **look alike **or sound alike.
E.g. In a PDL practise report: Flufeme & Norlevo:
Potential causes of a medication error involving Flufeme and Norlevo
* similiar colouring (pink)
* Both are S3 medicines - stored in close proximity
* As its S3 - not put through computer and no barcoade scanning - cannot verify if its the correct medication
Identify error-prone abbreviations
Errors can occur because meaning of abbreviations, symbols or terms is not clear
Example is in Week 1 notes (google docs)
identifyappropriate strategies to prevent LASA medication errors
- Store by therepeutic class rather than alphabetically
- Store alphabetically by generic name
- Store LASA apart
- Barcode scanning checks (makes sure the product you have taken from th shelve matches the product entered into the prescription) - correct med is dispensed through this process
- National TALL Man Lettering (combination of lower and upper case to highlight difference)
E.g. E.g. fluOXETine and fluVOXAMine
Discuss Literacy Levels in Australia and strategies to put in place for Individuals for those type of Individuals
Above the national average. Nearly 50% of Australians have low literacy levels
1. Write clear methods for others to follow
2. CLEAR LABELS for patients
- minimise information on main label. This can be done by using ancilllary labels where possible.
Discuss Numeracy Levels in Australia
Numeracy levels are slighly lower than the international average
Discuss Numeracy Levels in Australian Healthcare Professionals
Numeracy levels are low in healthcare professionals. In a study conducted by Aus and NZ researchers asked 5 calculation questions to 111 healthcare prof. Only 14% answered them correctly. In pharmacy there are lots of different ways to express numeracy information (e.g. 2% salycylic acid in aqeous cream APF ans 1 in 200 iodine solutio) and it can be diffiult to comprehend.
Healthcare Prof also had difficutly in interpreting decimal no.
List the ways to prevent numeracy errors
- Always write down working out even if it is only 1 step and always use a calculator
- Avoid using decimals where possible (e.g. measure 7ml not 7.03ml)
- Use unit dose products to avoid dosing errors
What is the selection attention theory?
In a pharmacy we are often repeating the same tasks throughout the day (e.g. scripts in, dispensing, checking meds) - pharmacists are better at finding errors and also better at missing errors
–> makes an assumption everything else is OK – convinces themselves that they are correct and dont see the bigger picture = less likely to double check. Potential solutions: **checklists, peer checks (double checks). **
Define: psychologicaltheorythatexplains how people focus on relevant information while ignoring distractions
Purpose of a checklist (self-assessment checklist)
Relayed to selection attention theory
- Slows you down and allows you to check if all aspects are correct to prevent any medication error
- however it is address our own assumptions (we are more likely to think everything is correct)
Purpose of a double check and list the approaches
Related to selection attention theory
External person sees if we have done incorrectly or missed - reduces medicaton error
1. Independant double checks: Student1 and2 complete their work separately then compare. PREFERRED!
2. Do and Show: Student1 shows student 2 their work and student 2 double checks if it is correct
3. Together: Student1 and2 complete their work together verbally
4. Watching: Student2watchesstudent2completetheirwork
