L17-L19 Medication Safety Flashcards
(45 cards)
Define a “just culture”.
Just culture seeks to create a system of workplace justice that CONSISTENTLY fostered open reporting, while simultaneously, holding people appropriately accountable for their actions.
- To remove fear
- Creates a culture of accountability; it is NOT punitive, NOR blame-free
Explain the tenets of a “just culture* in patient safety.
Just Response to 5 Behaviours:
1) Human Error:
- Unintended conduct, where actor should have done other than what they did
- Appropriate level of response: Accept/Console
2) At-Risk Behaviour:
- A choice where risk is not recognised or mistaken to be justified
- Appropriate level of response: Coach
3) Reckless:
- Conscious disregard of a substantial & unjustifiable risk of harm
- Appropriate level of response: Punish/Sanction/Dismiss
4) Knowledge:
- Knowingly causing harm (sometimes justified)
- Appropriate level of response: Punish/Sanction/Dismiss
5) Purpose:
- A purpose to cause harm (never justified)
- Appropriate level of response: Punish/Sanction/Dismiss
Each level of culpability has its own cause & its own solutions!
- (1) & (2) usually unintended, resulting in second victim of either pharmacist or staff committing the medication error
- All responses are independent of actual outcome!
What are the benefits of promoting a “just culture” when reporting medication errors?
1) Creates physiological safety for staff to report errors
2) Uses common language to consistently & fairly evaluate human (staff) behaviour.
3) Shifts the focus from errors & outcomes to system design & behavioural choices.
4) Creates a culture of accountability; it is NOT punitive, NOR blame-free
Define ‘side effect’.
Any unintended effect occurring at doses normally used in humans that is related to pharmacological properties of drug
- Can refer to positive or negative effect
Define ‘adverse drug reaction’.
WHO definition:
Reaction that is noxious/harmful and unintended and occurs at doses normally used in man for prophylaxis, diagnosis or treatment of disease of the modification of physiological function
- Exclude overdose, drug abuse & medication errors
- Include side effects i.e. injuries that are judged to be caused by drug
Define ‘adverse drug event’.
Injury due to medication that may or may not be preventable
- Preventable due to medication errors as e.g.
- Not preventable due to ADR or side-effect as e.g.
- Costly & result in significant additional healthcare resource consumption
Define ‘medication error’.
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the HCP, patient or consumer (i.e. medication use process).
Such events may be related to:
- Professional practice
- Healthcare products
- Procedures
- Systems, including prescribing, order communication, product labelling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring, use etc
That may result in:
- Adverse event, in which a patient is harmed
- Near miss, in which a patient is nearly harmed
- Neither harm nor potential for harm
Define ‘near miss’.
An event or situation that could have resulted in medication error, but did not.
- Either by chance or through timely intervention
- aka “close call”
Near misses, if ignored, may lead to medication errors reaching patients, since it is possible that they are at a systems level error
- Occurs 10-100x more often than adverse events
- Heinrich ratio: 1 major injury - 29 minor injuries - 300 near misses
Which category of patient outcomes are alternatively known as “near misses”?
Category B
Where do medication errors occur in the medication use process?
Errors & failures may occur at any point in the medication use process.
- For process to function optimally, HCP must consciously ensure that each step has been carried out properly.
- Consider safety at each step of the medication use process.
1) Prescribing
2) Preparation & Dispensing
3) Administration
4) Monitoring
Which step of the medication use process has the highest percentage of timely interception?
Prescribing
Which step of the medication use process has the lowest percentage of timely interception?
Administration
- Since it is almost unlikely to have a buddy to check, thus having the highest percentage of causing harm to patient.
How can medication errors occur in the prescribing step of the medication use process?
- Inadequate knowledge about drug indications and C/I
- Failure to consider individual patient factors, such as allergies, pregnancy/lactation, co-morbidities, DDI etc.
- Wrong patient, wrong drug, wrong dose, wrong route, wrong time
- Inadequate communication of administration plan between patient, pharmacist, nurses, doctors etc.
- Documentation is illegible, incomplete, ambiguous
- Mathematical error when calculating dosage or total quantity
- Incorrect data entry when using computerised prescribing (e.g. duplication, omission, wrong number, typo error)
How can medication errors occur in the preparation & dispensing step of the medication use process?
- Poor inventory control (e.g. LASA drugs placed together, expired products dispensed instead etc)
- Labelling & packaging mixed up
- Transcription errors (e.g. wrong interpretation of orders before keying into electronic systems, missing drugs in a list)
- Failure to consider individual patient factors, such as allergies, pregnancy/lactation, co-morbidities, DDI etc.
- Wrong patient, wrong drug, wrong dose, wrong route, wrong time
- Inadequate communication of administration plan between patient, pharmacist, nurses, doctors etc.
- Documentation is illegible, incomplete, ambiguous
- Mathematical error when calculating dosage or total quantity
- Incorrect data entry when using computerised prescribing (e.g. duplication, omission, wrong number, typo error)
How can medication errors occur in the administration step of the medication use process?
- Failure to consider individual patient factors, such as allergies, pregnancy/lactation, co-morbidities, DDI etc.
- Wrong patient, wrong drug, wrong dose, wrong route, wrong time
- Inadequate communication of administration plan between patient, pharmacist, nurses, doctors etc.
- Documentation is illegible, incomplete, ambiguous
- Omission / failure to administer, esp. important for OD drugs (e.g. T2DM pt requiring IV contrast for diagnostics man not have taken metformin SR on schedule & after which, drug was not administered for the day
How can medication errors occur in the monitoring step of the medication use process?
- Lack of monitoring for ADRs
- Drug not ceased if NOT working or course completed and yet to observe therapeutic effect
- Drug ceased before expected course completion
- Drug levels not measured or not followed up
- Communication failures
Identify the four factors that can contribute to medication errors.
1) Patient factors
2) Medication/Technology design factors
3) Staff factors
4) System/Workplace factors
Explain how patient factors can contribute to medication errors.
- Multiple medications (polypharmacy) or co-morbidities
- More than one doctor, requiring medication reconciliation
- Specific co-morbidities / conditions that warrant attention (e.g. renal/hepatic impairment, pregnancy/lactation, children/elderly etc.)
- Unable to communicate well
- Do not take an active role in their medication use
- Children & babies require dose calculations
Explain how medication/technology design factors can contribute to medication errors.
1) Poor drug manufacturing & distribution practices
- Inappropriate packaging or design leading to dosage form confusion
- LASA drugs / products
- Appearance too similar to another manufacturer
- Appearance too similar w/in same compant’s product line
- Inaccurate and/or incomplete labels
- Distracting symbols or logo
- Similarity in color, shape, and/or size to another product
- Similarity in color, shape, and/or size to same product, but of different strength
2) Complex or poorly designed technology
- Malfunction
- Wrong device selected (e.g. not using Handihaler w/ Spiriva)
- Adapters (e.g. parenteral vs enteral, Luer connectors, oxygen tank should ONLY connect to oxygen tubing, NOT IV tubing)
- Automated distribution / vending systems / automated counting machines / compounders w/ wrong input
- Oral measuring devices (e.g. syringes, cups, spoons)
- Infusion (e.g. PCA, infusion pumps)
Explain how staff factors can contribute to medication errors.
- Knowledge deficit
- Inexperience to know protocols that are in place
- Rushing
- Distracted w/ doing two things at once (may be unintentional)
- Interupptions
- Fatigue, boredom, auto-pilot (i.e. reduced alterness)
- Lack of checking & double-checking habits
- Violations to protocols and SOP
- Reluctance to use memory aids
- Poor teamwork and/or communication between colleagues
- Failed communication:
(a) Handwriting & oral communications
(b) Confusion w/ LASA drugs, different formulations (e.g. CR, SR, LA) or concentrations
(c) Missing / misplaced zeros & decimal points
(d) Confusion in units of measurement (e.g. mg, mcg, mL/min, mL/h)
(e) Use of non-standard abbreviations
(f) Ambiguous or incomplete orders
Explain how system/workplace factors can contribute to medication errors.
- Lighting and noise levels
- Frequent interruptions and distractions
- Absence of readily available medication & patient information
- Inappropriate storage of medications
- Inadequate staff numbers or staffing arrangement
(a) Lack of availability of HCP
(b) Assignment or placement of HCP or inexperienced personnel
(c) System for covering patient care - Breakdown of information system (computer), where multiple Rx will be affected at any one time
- Absence of safety culture in workplace
- Inadequate training & supervision
Why do medication errors occur, despite the fact that people working in healthcare are amongst the most educated & dedicated workforce in any industry?
1) Most errors occur as a result of “a chain of events set in motion by faulty system design that either induces error or make them difficult to detect, rather than lack of care & concern on the part of caregivers.
- Swiss cheese model of harm, where harm is the result of layers of defence in a system failing to prevent a hazard from reaching a patient
- One of the greatest contributors to accidents in any industry is human error.
- NOT the same as assigning blame as most human errors are induced by system failures (i.e. latent errors)
2) Latent errors / system failures are the greatest threat to safety in a complex system because they lead to operator errors
- i.e. failures built into the system & present long before the active error is manifested
- Difficult for people working in the system to see, since they may be hidden in computers or layers of management & ppl become accustomed to working around the problem
Explain the rationale for using a systems approach to modify the conditions that contribute to medication errors.
1) Common initial reaction is to find & blame someone for the error.
- However, even apparently single events or errors are due most often to the convergence of multiple contributing factors.
- Blaming an individual does NOT change these factors & the same error is likely to recur.
2) Errors are a form of information about a system that represent places in which the system failed & the breakdown resulted in harm.
3) Current responses to error tend to focus on active errors by punishing individuals, retraining or other responses aimed at preventing recurrence of the error
- May sometimes be appropriate, but in many cases, is NOT an effective way to make system safer.
4) If latent failures remain unaddressed, their accumulation actually makes the system more prone to future failures.
- Discovering & fixing latent failures and decreasing their duration are likely to have a greater effect of building safer systems than efforts to minimise errors at the point at which they occur
Explain what a ‘root cause analysis’ means.
RCA is a systematic approach to understanding the causes of an adverse event & identifying system flaws (i.e. latent errors) that can be corrected to prevent the error from happening again.
- Focusing on these causes & vulnerabilities is much more effective way to improve quality and safety than simply blaming the individual who made a mistake.
- Focusing on the system causes means analysing ALL factors that contributed to error (i.e. patient, technology design, staff & system errors)
Usually conducted by a team of 4-6 ppl
- Team should be interprofessional & include individuals at ALL levels of organisation who are close to, and have fundamental knowledge of issues and processes involved in the incident.
