Med Errors

Question 1

The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
Two kinds?

Answer 1

Medical error
Error in execution
Error in planning

Question 2

Medical errors result in injury to how many hospitalized patients per year?

Answer 2

44,000-98,000 per year

1 in every 25

Question 3

What are the three leading causes of death in America?

Answer 3

Heart disease
cancer
medical errors

Question 4

Healthcare system decentralized and fragmented. Results in lost info on lab and diagnostic test, or medical information. Hand-off communication

Answer 4

Inadequate information flow

Question 5

Human problems in medical errors

Answer 5

Fatigue, illness, drug use. Long shifts, interruptions.

Patient-related issues: inadequate ID

Question 6

Deficiencies in orientation and training

Answer 6

Organizational transfer of knowledge

Question 7

Inadequate staffing, lack of supervision

Answer 7

Staffing patterns

Question 8

Equipment failures in medical errors?

Answer 8

Implants, poorly designed equipment, inadequate instruction

Question 9

Inadequate policies and procedures

Answer 9

Poorly documented, non-existent, or clinical inadequate procedures

Question 10

Factors include poor design system and inadequate organizational strategies

Answer 10

System-based errors

Medication, surgical, healthcare-associated, diagnostic

Question 11

Failure to administer ordered medication

Answer 11

Omission errors

Question 12

Any dose, strength, or quantity that is inappropriate for patient or different than prescribed

Answer 12

Improper dose/quantity erros

Question 13

Medication dispensed and/or administered that was not authorized by the prescriber

Answer 13

Unauthorized drug errors

Question 14

Medication medical errors?

Answer 14

Brand names look or sound alike, labels are hard to read, look-alike packaging, lack of standards in contents display, inconsistent warnings

Question 15

What are some prescribing errors?

Answer 15

Decline in renal or hepatic function 
History of allergy
Wrong drug, dosage form/abbreviation
Incorrect dosage calculation
Illegible handwriting or incomplete orders
Use of error-prone terms

Question 16

What are vulnerable patients when it comes to medical errors?

Answer 16

Elderly: polypharmacy, falls, slow metabolism
Children: dose calculations, communication
ICU patients: medication erros, complexity of care
Language barriers

Question 17

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

Answer 17

Sentinel event. Requires immediate investigation and response.

Question 18

A process for identifying the basic or casual factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event

Answer 18

Root cause analysis. Who was involved, when it happened, what happened, why is happened, and what to do to prevent it from happening again

Question 19

What are basic types of root causes?

Answer 19

Physical causes: material items failed in some way
Human causes: someone did something incorrectly
Organizational causes: a system, policy, or process is faulty

Question 20

Analyze the data from the review of sentinel event, root cause analysis, and risk reduction measures

Answer 20

The Joint Commission

Question 21

Non-profit with mission to educate healthcare community and consumers about safe med practices

Answer 21

Institute for Safe Medication Practices

Directs the medication error reporting system

Question 22

What can be done to prevent medical errors?

Answer 22

Clarify order, question medication, document immediately, learn your meds, report all errors/near misses, med reconciliation, pharmacist participation, med standardization, marking incision site, time-out before procedure

Question 23

How to take verbal orders?

Answer 23

Verify the full name of patient and person giving the order. Obtain verbal/telephone order and write it on the physician’s order from, read back the entire order to verify, ensure legibility, flag and highlight verbal order

Question 24

How to prevent catheter-assocaited urinary tract infections (CAUTI)?

Answer 24

Limit use and duration, use aseptic technique, secure for unobstructed urine flow, maintain sterility of urine collection system, replace collection system when required, collecting urine samples

Question 25

Evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes

Answer 25

Core measure

Question 26

Why are core measures important?

Answer 26

Core measure care is the right care every time. Reduces morbidity, reduces mortality, reduces complications and readmissions. It is the best evidenced-based care for your patients.

Question 27

What does HCAHPS stand for?

Answer 27

``` Hospital consumer assessment of healthcare providers and systems ```

Question 28

A nationally standardized patient satisfaction survey from the Center for Medicare and Medicaid Services (CMS)

Answer 28

HCAHPS | Measures and publicly reports patient's experiences in our country's hospitals

Question 29

What number and types of questions does HCAHPS include?

Answer 29

27 survey items Communication with doctors and nurses, responsiveness of the hospital staff, pain control, communication about meds, physical environment, discharge information

Question 30

What are common sentinel events?

Answer 30

Retention of foreign body, wrong patient/site/procedure, delay in treatment, OP/Post-OP complications, suicide, falls, criminal events, med errors, perinatal death/injury, other unanticipated events