Managing Pharmacy Systems for Safety Flashcards
(36 cards)
What does the term system failure mean?
Key source of potentially preventable events e.g. medication error
- Likely in health where complex systems and technologies are used
What is clinical risk management?
Clinical risk management aims to identify, prevent and manage unexpected events that can cause patient harm
What are some methods for continuous quality improvement (CQI)?
- Practice Standards
- Clinical Audit
> Quality improvement process that aims to improve patient care and outcomes through a systematic review of care ag
- Total Quality Management
> ‘Plan-Do-Check-Act’
- Benchmarking
> Best practices that will lead to superior performance
How to design healthcare systems that are safer for patients and healthcare staff (system review and redesign)?
Change concepts
- Simplification, standardisation and reduced reliance on memory
> Process design e.g
- Reduce complexity by simplifying processes
- Reduce variation by standardising equipment and procedures
> Organisational change e.g.
- Optimise the work environment (e.g. reduce noise and change shifts to reduce worker fatigue)
- Train for teamwork (encourages communication and coordination of effort; may provide support to team members)
How to record medication incident reporting (Method that reduces serious adverse events)?
Medication incident reporting (actual and near-misses)
- Description of incident: what, where, when
- Context and contributors: how and why
- Outcome or impact
- Factors that could have minimised impact
- Actions proposed / taken: systems approach
What are the two standards (safety and professional) that should be applied to assure the provision of quality of pharmacy services?
- Australian Commission on Safety and Quality in Health Care
- National Safety and Quality Health Service (NSQHS) Standards
What were the National Safety and Quality Health Service (NSQHS) Standards developed for? What does it describe?
- NSQHS Standards were developed to protect the public from harm and improve the quality of health care
- Describe the level of care that should be provided by health service organisations and the systems that are needed to deliver that care
There are EIGHT National Safety and Quality Health Service (NSQHS) Standards, what are the THREE that is most important to pharmacists?
- Clinical Governance: aims to ensure systems are in place to maintain and improve the reliability, safety and quality of health care
- Partnering with Consumers
- Preventing and Controlling Healthcare-Associated Infection
- Medication Safety:
- aims to ensure clinicians safely prescribe, dispense and administer appropriate medicines, and monitor use
- consumers informed about medicines, understand their own medicine needs and risks
- Comprehensive Care
-
Communicating for Safety:
* aims to ensure effective communication between patients, carers and families, multidisciplinary teams and clinicians, and across the health service organisation, to support continuous, coordinated and safe care for patients - Blood Management
- Recognising and Responding to Acute Deterioration
What information does the documentation of patient information provide to clinicians (NSQHS Standard 4: Medication Safety)?
Medication reconciliation
- Clinicians take a best possible medication history, which is documented in the healthcare record on presentation or as early as possible in the episode of care
- Clinicians review a patients current medication order against their best possible medication history and the documented treatment plan, and reconcile any discrepancies on presentation and at transitions of care
Adverse drug reactions
- Health service organisation has processes for documenting a patient’s history of medicine allergies and adverse drug reactions in the healthcare record on presentation
- The health service organisation has processes for documenting adverse drug reactions experienced by patients during an episode of care in the healthcare record and in the organisation-wide incident reporting system
- The health service organisation has processes for reporting adverse drug reactions experienced by patients to the TGA in accordance with its requirements
Health Service Organisation = Hospital
What information does the continuity of medication management provide to clinicians (NSQHS Standard 4: Medication Safety)?
Medication review (health service organisations has processes)
- To perform medication reviews for patients
- To prioritise medication reviews, based on a patient’s clinical needs and minimising the risk of medication-related problems
- That specify the requirements for documentation of medication reviews, including actions taken as a result
Information for patients
- Health service organisation has processes to support clinicians to provide patients with information about their individual medicines and risks
Provisions of a medicines list (health service organisation has processes to
- Generate a current medicines list and the reasons for any changes
- Distribute the current medicines list to receiving clinicians at transitions of care
- Provide patients on discharge with a current medicines list and the reasons for any changes
What does the medication management process include (NSQHS Standard 4: Medication Safety)?
Information and decision support tools for medicines
- Health service organisation ensures that information and decision support tools for medicines are available to clinicians
Safe and secure storage and distribution of medicines
- Safe and secure storage and distribution of medicines
- Storage of temperasture-sensitive medicines and cold chains management
- Disposal of unused, unwanted or expired medicines
High-risk medicines
Health service organisation
- Identifies high-risk medicines used within the organisation
- Has a system to store, prescribe, dispense and administer high-risk medicines safely
What diseases are the current ACSQHC Clinical Care Standards used for?
CCS: care that should be offered by a health professional and provided by health services
- Acute coronary syndromes
- Acute stroke
- Antimicrobial stewardship
- Cataract clinical care standard
- Delirium
- Heavy menstrual bleeding clinical care standard
- Hip fracture care
- Osteoarthritis of the knee
- Venous thromboembolism prevention clinical care standard
What are the resources used for ACSQHC medication safety?
- Hospital medication charts
- Medication reconciliation
- Safer medicines administration
- Safer naming, labelling and packaging of medicines
- High risk medicines
- Electronic medication management
- Quality use of medicines in hospitals
- Medication safety in mental health
- Medication safety tools and resources
What is the Quality Care Pharmacy Program (QCPP)? Who was it developed by? What do pharmacists applying for accreditation have to do?
- Quality assurance program for community pharmacy
- Developed by Pharmacy Guild, Pharmaceutical Society of Australia and other industry stakeholders
- QCPP was recognised as Australian Standard 85000:2011: quality management system for pharmacies in Australia
- Pharmacies applying for accreditation are required to complete several steps before being assessed
What are the FIVE domains of the Quality Care Pharmacy Program (QCPP)?
- Business management and governance
- Human resources
- Premises, infrastructure and stock
- Customer experience
- Pharmacy services
What are the FOUR sub-groups of professional practice standards (total of 16 standards)?
- Foundations of practice
- Providing therapeutic goods
- Providing health information
- Delivering Professional Services
How many domains does the national competency standards framework have?
FIVE DOMAINS
What is root cause analysis and action (RCA2)? what is the objective?
Process used to understand WHAT happened, HOW and WHY errors or near-misses have occurred
Objective: prevention of future harm and improved patient safety
Not to punish staff –> systems-approach to preventing future incidents
What is the systems-approach to improving safety?
“Preventing errors means designing the health care system at all levels to make it safer. Building safety into processes of care is a much more effective way to reduce errors than blaming individuals”
What are examples of blameworthy-events?
- criminal acts
- patient abuse
- alcohol or substance abuse on the part of the provider
- acts defined by the organization as being intentionally or deliberately unsafe e.g. not following organisational policies and procedures
What is the process for root cause analysis and action (RCA2)?
- Triage adverse events and close calls/near misses
- Identify the appropriate RCA2 team size and membership
- Establish RCA2 schedules for execution
- Use tools to facilitate the RCA2 analysis
- Identify effective actions to control or eliminate system vulnerabilities
- Develop Process/Outcome Measures to verify that actions worked as planned and feedback to staff who reported the incident
- Use tools for leadership to assess the quality of the RCA2 process
What are three 3 steps for the RCA2 Process?
- Event, hazard, system vulnerability (immediate action are taken to care for the patient) -> risk-based prioritization (one-person is responsible for applying the risk matrix)
- What happened (fact finding and flow diagramming) –> development of casual statements –> identification of solutions and corrective actions
- Implementation –> measurement (process or outcome measure identifying what will be measured, the expected compliance level and the date it will be measured) –> feedback (provided to CEO/board among others)
RCA2 TEAM IS NOT RESPONSIBLE FOR ANY ACTIVITIES IN STEP3
For identifying and classifying events;
A) What is risk-based prioritization?
B) What does It incorporate?
C) what is a useful tool?
D) What does a ranked matrix score of 3,2,1 mean?
A)
Risk-Based Prioritization of Events, Hazards, and System Vulnerabilities
- Prioritizes issues that may not yet have caused harm so that these hazards and vulnerabilities can then be mitigated or eliminated before harm occurs
B)
- Incorporates assessment of the outcome severity or consequence and its probability of occurrence (severity and probability)
C)
Saferty Assessment Codes Matrix: Risk Matrix
Risk Matrix (safety assessment codes matrix)
- Severity of the event
- Probability of occurrence
- Predefined steps that will be taken when matrix thresholds established by the organization are reached
D)
Safety Assessment Codes Matrix: Risk Matrix
When a severity category is paired with a probability category, a ranked matrix score results
- 3 = highest risk
- 2 = intermediate risk
- 1 = lower risk
see attached image
For Risk Matrix: Severity Categories
A) What are the key factors when determining severity?
B) How to assign severity for actual adverse events?
C) How to assign severity for near misses?
D) What are the FOUR severity categories (national patient safety foundation)?
A)
- Extent of injury
- Length of stay
- Level of care required for remedy
- Actual or estimated physical costs
B)
- Based on actual patients condition
C)
- On reasonable worst-case system levels scenario
D)
- Catastrophic, major, moderate, minor
- see attached image
