Med Safety Flashcards
(24 cards)
what is ‘Just Culture’ in patient safety
- seeks to create a system of workplace justice that fostered open reporting, while simultaneously holding people appropriately accountable for their actions
benefit of ‘Just Culture’ in patient safety
- creates psychological safety for staff to report errors
- uses common language to consistently and fairly evaluate human behavior
- shift focus from errors and outcomes to system designs and behavioral choices
- creates accountability, not punitive nor blame-free
what is side effect
a known effect, other than primarily intended, relating to the pharmacological properties of a medication (eg. n&v)
what is ADR
any response to a meds that is noxious and unintended (Eg. hypersensitivity)
what is 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 healthcare professional, patient or consumer
can lead to:
- adverse event (pt is harmed)
- near miss (pt almost harmed)
- neither harm nor potential for harm
what is a near miss event
an event or situation that could have been resulted in med error but did not (usually by chance or though timely intervention)
- if near miss is ignored may lead to med errors reaching pt
what is an adverse drug event
an injury due to medication
- may be preventable (due to medication error)
- may not be preventable (ADR or SE of meds)
steps involved in patient using medication
- prescribing
- preparation and dispensing
- administration (highest error rate)
- monitoring
errors in administration
- wrong patient, drug, dose, time, route
- omission, failure to administer
- inadequate documentation
errors in monitoring
- lack of monitoring for ADR
- drug not ceased if not working
- drug ceased before complete course
- drug levels not measured or follow up (@ right time)
- communication error
patient at higher risk of med errors
- multiple meds or health conditions
- with more than 1 doctor
- specific conditions (renal/ hepatic impairment, preg)
- cannot communicate well
- not actively in charge of their own meds
- children/babies (where dose cal is required)
errors due to medication/ tech design factors
- poor drug manufacturing/distribution practices (packaging, color)
- complex or poorly designed technology
staff/ human errors
- knowledge deficit
- inexperience
- rushing
- distracted/ interruptions
- fatigue (man mode)
- SOP violations
- poor teamwork
- failed communications
errors due to system/workplace factors
- lighting/ noise
- disruptions
- lack of safety culture
- lack training/ supervision
- inappropriate storage
- understaffed
how is swiss cheese model relevant
errors usually occurs as a result of a chain of events set in motion, leading to a chain effect, which is hard to detect
latent errors or system failures
pose the greatest threat to safety in a complex system because they lead to operator errors.
- built into the system and present long before the active error
- difficult for people working in the system to see as they may be hidden in computers or layers of management
Root cause analysis (3 question)
- what happened (key steps)
- what went wrong and why (identify failed processes)
- what to do to prevent incident recurrence and suggest risk-reduction strategies
steps to reduce errors
- reduce reliance of (human) memory
- simplify
- standardise
- use forcing and constraints functions
- use protocols and checklist wisely
- improve access to information
- decrease reliance on vigilance
- reduce handoffs
- differentiate, eliminate look-alikes and sound alikes
- automate carefully
what are high-alert meds
drugs that bear a heightened risk of causing significant patient harm when used in error
- mistakes may or may not be more common
- but consequences of an error are more devastating
Recommended guidelines for high-alert medications management
- eliminate or reduce the possibility of error
- remove high alert from clinical areas; limit available concentrationand volume - make errors visible
- independent double checking for infusion pump settings to catch errors - minimise the consequences of errors
- change practices to reduce the Adverse Effects of errors
- close monitoring to improve early detection of errors
advantages of CPOE
- elimination of handwriting discrepancies
- immediate error checking for dosage, frequency, ROA
- drug interactions and allergy checking
- serving DI databases
- tool to document administration of medications by nursing
- immediate transmission of orders to multiple disciplines
- providing data to analyse drug utilisation and workflow
- increase formulary adherence and compliance to prescribing guidelines
- allowing price comparisons
- intelligent prescribing
ISMP recommendation
- use generatic names
- avoid including salt of chemicals
- differentiate generic names from brand names
- standardise inclusion of suffixes
- standardise use of mnemonics or short names
- standardise font (size, style and color)
Closed Loop Medication Management system (CLMM)
- enhanced medication safety process (ensure right patient, drug, dose, time)
- efficiency of ward processes:
- reduced turn around time for medication stock
- reduced time required to administer medications to patients
components of CLMM
- Electronic Inpatient Medication Record system- eIMR
- Clinical Decision Support System- CDSS
- inpatient Pharmacy Automated System- iPAS
- Electronic Medication Administration Record System- eMARS
