Exam 1 Flashcards
(48 cards)
Identify technology that can be used to mitigate medication errors
Computerized physician order entry (CPOE)
Clinical decision support (CDS)
Bar coding
Automated dispensing device (ADD)
Smart intravenous infusion pumps
Describe the medication use process
order the drug, transcribe the drug (read and interpret drug correctly), dispense the drug, administer the drug
Describe the role of various systems and factors in creating safety and in causing errors during the prescribing process
prescribing decision: prescriber factors, patient factors, medication factors, patient preferences, organizational factors
causes of prescribing errors: individual factors, team factors, work environment factors, patient factors, latent conditions
Identify aspects of the medication use and dispensing processes as they pertain to medication errors
dispensing process: receipt of Rx, legal check of Rx, clinical check of Rx, label generation, stock selection, medication assembly, product labeling, final accuracy check, patient counseling
medication use: ensure patient is receiving right dosage and instructions on how to use it, make sure patient is using medication correctly and taking it at the right times
Differentiate between a medication error and a near miss
a medication error is an error that reaches the patient and does direct harm
a near miss is an error that does not reach the patient but occurred in the medication process
List the types of potential medication errors associated with administration
wrong dose, choice, time, frequency, drug, time, technique, route
known allergy
preparation error
missed dose/omission
extra dose
inadequate monitoring
Describe the steps in the administration process that are intended to prevent medication errors and adverse drug
events
right patient (2 identifiers)
right med
right dose
right route
right time
right documentation
Identify the purpose of medication reconciliation
Process of identifying and maintaining the most accurate list of all medications a patient is taking
Using this list to provide correct
medications for the patient anywhere
within the healthcare system
Especially at transfer of care
Understand the concepts of Adverse Drug Reaction
type A –> predictable, common and less serious, well documented before licensing
type B –> rare, unexpected, potentially serious or fatal, usually not dose dependent, not usually documented before licensing
Identify the risk factors (vulnerable populations) of ADR
elderly patients
neonates and children
ethnic variations
genetic variations
renal dysfunction
liver disease
gender
multiple drug use
allergies
inappropriate administration
pregnancy
breastfeeding
Reporting ADR/Management ADR/Drugs that most frequently caused ADRs
The FDA Adverse Event Reporting System (FAERS) is a database that collects
information on adverse event and medication error reports submitted to FDA.
MedWatch is the Food and Drug Administration’s (FDA) program for reporting
serious reactions, product quality problems, therapeutic inequivalence/failure, and product use errors with human medical products,
including drugs, biologic products, medical devices, dietary supplements, infant formula, and cosmetics
Questions to ask to identify an ADR
* Have any new drugs been started?
* How soon after starting the new drug did the reaction occur?
* Could the reaction be due to the medical condition or to
another disease?
* May the ADR have been precipitated by a patient factor?
* Could it have been precipitated by a drug interaction?
* Did the reaction stop when the drug was stopped?
* Did the reaction re-occur when the drug was restarted?
* Is it the drug, or an excipient that has caused the ADR?
* Is it an allergic reaction?
antidepressants and opioids most commonly cause ADRS
Drug interaction/examples
Pharmacodynamic: Interactions occur when a medicine modifies the effect of another medicine but without altering the blood
level of that medicine
* Coadministration of a beta-blocker with a beta-agonist may give rise to bronchospasm and limiting
the effect of beta agonist
* Combination of ACE inhibitor and Potassium sparing diuretic both increase potassium levels and can cause fatal hyperkalemia
Pharmacokinetic
* Interaction at site of absorption
* Distribution interactions
* Metabolism interactions
* Excretion interactions
Identify the purpose of reporting medication incidents
Medication error is seldom attributed to any
one individual or factor:
▪ Poor teamwork and communication
▪ Insufficient or missing information
▪ Illegibility
▪ Inadequate training
▪ Excessive workload
▪ Staff shortages
▪ Interruptions and distractions
Need to report to facilitate identifying
system problems and correcting them to
prevent future errors
Identify medication events that should be reported
Any unintended or unexpected incident,
which could have or did lead to harm for one
or more patients
Adverse drug event
Adverse drug reaction
Medication Reaction
Near Miss
Identify who reports should be sent to
Product manufacturer
Equipment and technology vendor
The Joint Commission – Sentinel Events
Food and Drug Administration (FDA)
o FDAs Adverse Event Reporting System (AERS); part of FDAs MedWatch program
Institute for Safe medication Practices (ISMP)
Medication Error Reporting Program (MERP)
Patient Safety Organizations (PSOs)
Describe deterrents to reporting medication incidents
Hierarchical hospital culture/structure where
nursing staff disagreed about the definition of
reportable errors
Fear of response of administrators and peers
to a reported error
Amount of time and effort involved in
documenting and reporting an error
Describe strategies to encourage reporting of medication incidents
Agreement on the definition of an error
Supporting and simplifying error reporting
Institutionalizing a culture of justice
Learning is encouraged and blaming is discouraged
Capitalizing on reports to determine system
factors contributing to error
Positive incentives for medication
administration error (MAE) reporting
Anonymous “hot line”
Identify common communication strategies in the healthcare system and their potential influence on medical error propagation
emailing colleagues, phone and fax are primary means –> miscommunication makes up 80% of reasons for error so make sure to communicate appropriately in these ways
Review supported tools and behaviors to improve teamwork and communication
shared mental models, mutual respect, trust, close-loop communication
Apply effective communication strategies to mitigate medical related errors
- concrete –> clear picture of what’s being said, data backs this up
- coherent –> logical and understood
- clarity –> goals/purpose stated
- commitment –> measures dedication to argument, delivered well –> increases morale
- consistency –> choice of words matter, utilize least possible words, no repetition
- completeness –> each message must have logical conclusion
- courteous –> relay that you’re honest, respectful, open, and polite
Define patient safety and describe “acceptable minimum”
current knowledge, resources available, context in which care is delivered vs. risk of non-treatment or other treatment
Compare and contrast iatrogenic adverse events, patient safety incidents, and critical incidents
iatrogenic adverse events –> occur as a result of medical management and result in measurable disability, negligent adverse events are those events caused by a failure to meet standards of care reasonably expected of the average healthcare professional
patient safety incidents –> an unintended/unexpected incident that could’ve or did harm a patient, includes near misses
critical incidents –> incidents that are uniquely pivotal: desirable or undesirable, significant for potential/actual harm, event may reveal important hazards
Describe the Swiss Cheese Model in relation to healthcare
healthcare systems have lots of preventative measures in place to prevent medical errors and near misses, but when there are “holes” in these measures a problem can bypass them when aligned perfectly and cause harm
Describe the complexities of healthcare systems and how this can affect patient safety
multiple-complex components
interacting with one another to
achieve a measurable outcome
routine tasks connect multiple
people, activities, and
technologies
social factors –> psychological, team dynamics & communication, managerial
technical factors –> equipment, information technology support/access, infrastructure
safety improvement efforts needed to be targeted at this components
