Medication Safety

Question 2

Medication error:

Answer 2

is 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.

-“ This can include errors made in prescribing, order communication, product labeling, and packaging, compounding, dispensing, administration, education or monitoring”.

Question 3

Medication error are:
- Preventable

Adverse Drug Reactions (ADRs) are:
- Not preventable
- Usually not avoidable

Question 4

At Risk Behaviors that can compromise patient safety:

Drug and patient-related:
- failure to check/reconcile home medications and doses
- dispensing medications without complete drug knowledge
- Not questioning unusual doses
- Not checking/verifying allergies

Communication:
- not addressing questions/concerns
- rushed communication

Technology:
- overriding computer alerts without proper consideration
not using available technology

Work environment:
- trying to do multiple things vs. focusing on a single complex task
- inadequate supervision and orientation/training

Answer 4

Community Pharmacy:

Use a second patient identifier.
Ask for the patients address or date of birth in addition to the patients name.
Open the bag.
Employ technology. Flag patients with similar names.
Educate patients.

Question 5

Sentinel event:

Answer 5

is an unexpected occurrence involving death or serious physical injury of a patient.

Question 6

Errors of Omission- “OMI” like omitted

Answer 6

Something was left out that is needed for safety.

ex. failing to use a pharmacist double check system for chemotherapy orders.

Question 7

Error of Commission- “Commi” like committed a crime

Answer 7

Something was done incorrectly.

ex. prescribing bupropion to a patient with a history of seizures.

Question 8

System Based Causes:

• Focus on the system, not the individual. [Instead of placing blame on the individuals, healthcare professionals should find ways to improve the system (“just culture”)]
• Errors will always occur, but the goal is to design systems to prevent medication errors from reaching the patient.

Answer 8

In a just culture, safety is valued, reporting of safety risks is encouraged without penalization, and a clear and transparent process evaluates the errors.

Question 9

automated dispensing cabinet

Answer 9

• used to reduce medication errors
• reduce pharmacy workload

Question 10

Response:

A medication error occurred. What should be done?
Take care of the patient.

Immediately report the error.
Document the error.
External notification
Investigation: RCA (Root Cause Analysis)
Improvement

Answer 10

[Telling the patient]
The patient should be told about the error.
- the pharmacist is typically the one to report a medication error
- circumstances leading to the error should be explained completely and honestly
- patient should understand the nature of the error, what effects the error may have, how he or she actively prevent errors in the future.

——————————————————————————————————————–[Telling the physician]
- the physician must be contacted if the error will lead to a side effect.
- the prescriber must be notified if the error will cause an adverse drug reaction.
- the physician must be told if the error will impact the disease being treated.

Question 11

Response:

Institutions should have a plan in place for responding to medication errors. The plan should address the following:

1)
2)
3)
4)
5)

Answer 11

1) Internal notification
- who should be notified within the institution and within what time frame?

2) External notification
- who should be notified outside of the institution?

3) Disclosure
- What information should be shared with the patient/family? Who will be present when this occurs?

4) Investigation
- What is the process for immediate and long-term internal investigation of an error?

5) Improvement
- What process will ensure that immediate and long-term preventative actions are taken?

Question 13

Root Cause Analysis:

Answer 13

**- is a retrospective investigation of an event that has already occurred, which includes reviewing the sequence of events that led to the error.
- the information obtained in the analysis is used to design changes that will hopefully prevent future errors.

• What happened primarily, that caused the event to occur.

Question 14

Reporting:

what should be reported?

Answer 14

• medication errors
• preventable adverse drug reactions
• hazardous conditions
• “close calls” or “near misses”

Should be reported.

-Medication errors are reported so that changes can be made to the system to prevent similar errors in the future. Without reporting, these events may go unrecognized and will likely happen again because others will not learn from the incident.

Question 15

Reporting:

Community Pharmacy:

• Staff member who discovers the error reports to corporate office (follow designated reporting structure)

OR

• To the owner of an independently owned pharmacy
• Report within 48 hours (state specific) [Document and begin RCA]
• Many states require that the patient and prescriber are also notified as soon as possible

Answer 15

“The fundamental purpose of reporting systems is to learn how to improve the health care delivery process to prevent errors.”

• Many state boards of pharmacy require quality assurance programs to promote pharmacy processes that prevent medication errors.

Question 16

Reporting:

Hospital:

-** report via Medication Event Reporting System - MERS
- **report to Pharmacy & Therapeutics committee and Medication Safety Committee

Question 17

Organizations that specialize in error prevention:

• The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of Patient Safety Organizations (PSOs)
• The Agency for Healthcare Reseach and Quality (AHRQ) administers the provisions of the Patient Safety Act and rules for PSOs
• The ISMP National Medication Errors Reporting Program (MERP): confidential national voluntary reporting program
  [ISMP- Institute for Safe medication Practices]
• On the ISMP website (www.ismp.org), medication errors and close calls can be reported.
• • • Click on “Report Errors”

Answer 17

• ISMP National (MERP) Medication Errors Reporting Program: is a confidential, voluntary reporting program
• ISMP website (www.ismp.org), medication errors and close calls can be report

Question 18

Evaluation & Quality Improvement:

Can be performed _______

Answer 18

• prospectivity
• retrospectively
• continuously

Question 19

Evaluation & Quality Improvement:

Prospective-

prospective analysis

Answer 19

(FMEA) Failure Mode & Effects Analysis:
- is a proactive method used to reduce the frequency and consequences of errors. FMEA is used to analyze the design of a system in order to evaluate the potential for failures and to determine what potential effects could occur when the medication delivery system changes in any substantial way OR if a potentially dangerous new drug will be added to the formulary.

Question 20

Evaluation & Quality Improvement:

Retrospective-

Answer 20

(RCA) Root Cause Analysis:
- is a retrospective investigation of an event that has already occurred, which includes reviewing the sequence of events that led to the error. The information obtained in the analysis is used to design changes that will hopefully prevent future errors.

Question 21

RCA

Identify the problem
Define the problem
Understand the problem
Identify the root cause
Corrective action
Monitor the system

Question 22

Evaluation & Quality Improvement:

Continuous-

Answer 22

(CQI) Continuous Quality Improvement:
- is the goal for most healthcare settings.
- CQI programs improve efficiency, quality, and patient satisfaction while reducing costs.

ex. Lean and Six Sigma, which are often used together. Lean focuses on minimizing waste, while Six Sigma focuses on reducing defects.
Six Sigma uses DMAIC (define, measure, analyze, improve, control) process.

Question 23

Reporting- Adverse Drug Reactions:

• at MedWatch Food and Drug Administration

Question 24

Evaluation & Quality Improvement:

A root cause analysis (RCA) retrospective analysis of the sequence of events that led to the error.

Identifying the sentinel event: is an unexpected occurrence involving death or serious physical or psychological injury of a patient.

Findings from the RCA are used to improve the system and prevent repeated events.

Question 25

At-Risk Behaviors that can compromise Patient Safety: Drug and Patient-Related: - failure to check/reconcile home medications and doses - dispensing medications without complete knowledge of the medication - not questioning unusual doses - not checking/verifying allergies Communication: - Not addressing questions/concerns - Rushed communication Technology - Overriding computer alerts without proper consideration - Not using available technology Work Environment - Trying to do multiple things vs. focusing on a single complex task - Inadequate supervision and orientation/training

Question 26

The Joint Commission (TJC): - Independent, not-for-profit organization that accredits and certifies more than 17000 healthcare organizations and programs in the US, including hospitals. - TJC: they are concerned about safety and standards, with onsite visits -TJC focuses on the highest quality and safety of care and SETS standards that institutions must meet to be accredited. - An accredited organization must undergo an on-site survey at least every 3 years, and surveys can be unannounced.

Answer 26

not for community pharmacies but for hospitals, infusion centers, long term care facilities, "Hospitals are Accredited by The Joint Commission (TJC)" - if you do not pass the accreditation, Medicare will not pay for services at that hospital.

Question 27

National Patient Safety Goals (NPSGs): ) Use at least 2 patient identifies when providing care, treatment and services. What are appropriate patient identifiers? What are inappropriate patient identifiers and should NOT be used? ------------------------------------------------------------------------------------------------------------------ ) Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. What elements should be included? ------------------------------------------------------------------------------------------------------------------- ) Maintain and communicate accurate patient medication information. What does this include?

Answer 27

What are appropriate patient identifiers? - patients name - patients DOB - medical record number What are inappropriate patient identifiers and should NOT be used? - zip code - room number - physician name -------------------------------------------------------------------------------------------------------------------- - There are many important elements to this goal, including the requirements to use approved - dosing protocols & programable pumps (e.g. for heparin) and to provide education to patients and families. - Protocols should include STARTING DOSE ranges, ALTERNATE DOSING STRATEGIES to address drug-drug interactions. - COMMUNICATION with the dietary department to ADDRESS DRUG-FOOD INTERACTIONS, general monitoring requirements and monitoring for bleeding and heparin-induced thrombocytopenia. ---------------------------------------------------------------------------------------------------------------------------------- - This includes MEDICATION RECONCILAITION, providing written information to the patient and CONDUCTING DISCHARGE COUNSELING. The medication name, dose, frequency, route, and indication (at a minimum) should be confirmed.

Question 28

National Patient Safety Goals (NPSGs): [These are from The Joint Commission] - Label all medications on and off the sterile field. Label all medication containers (e.g. syringes) and other solutions on and off sterile field in perioperative and other procedural settings. - - Reduce harm associated with anticoagulant therapy - - Maintain and communicate accurate patient medical information - - Report critical results (labs tests and diagnostics procedures) on a timely basis - - Comply with CDC or WHO (world health organization) hand hygiene guidelines - - Reduce healthcare associated infections - - Improve the safety of clinical alarm systems

Question 29

"infection picked up in a healthcare setting" =

Answer 29

Nosocomial "Hospital Acquired"

Question 30

While TJC is the most recognized accreditation body, 3 other organizations accredit and certify healthcare programs: 1 2 3

Answer 30

1- DNV GL Healthcare 2- Healthcare Facilities Accreditation Program-Accreditation Association for Hospitals/Health Systems (HFAP/AAHHS) 3- (CIHQ) Center for Improvement in Healthcare Quality

Question 31

Common Methods To Reduce Medication Errors: - Avoid "DO NOT USE" abbreviations - Abbreviations are unsafe and contribute to many medical errors. TJC standards include recommendations against the use of unsafe abbreviations. - - The minimum list of "DO NOT USE" abbreviations per TJC is shown in the table. - - The (ISMP) Institute for Safe Medical Practices, also publishes a list of error-prone abbreviations, symbols, and dosage designations which include those on TJC's list and may others

Answer 31

DO NOT USE: Potential Problem: Use instead:

Question 32

DO NOT USE: U, u (unit) Potential Problem: Use instead:

Answer 32

Potential Problem: Mistaken for "0"(zero), the number 4 (four) or cc Use instead: Write "unit"

Question 33

DO NOT USE: IU (international unit) Potential Problem: Use instead:

Answer 33

Potential Problem: Mistaken for IV (intravenous) or the number 10 (ten) Use instead: Write "international unit"

Question 34

DO NOT USE: Q.D, QD, q.d. (daily) Q.O.D, QOD, q.o.d qod (every other day) Potential Problem: Use instead:

Answer 34

Potential Problem: - Mistaken for each other. - Period after the Q mistaken for "I" and "O' mistaken for "I' Use instead: Write "daily" Write "every other day"

Question 35

DO NOT USE: Trailing zero (X.0 mg) Lack of leading zero (.X mg) Potential Problem: Use instead:

Answer 35

Potential Problem: - Decimal point is missed resulting in a 10-fold dosing error Use instead: Write X mg - Do NOT Use a trailing zero. Write 0.X mg - must use a leading zero.

Question 36

DO NOT USE: MS Potential Problem: Use instead:

Answer 36

Potential Problem: - can mean morphine sulfate or magnesium sulfate Use instead: - Write "morphine sulfate"

Question 37

DO NOT USE: MSO4 , MgSO4 Potential Problem: Use instead:

Answer 37

Potential Problem: - confused with one another Use instead: - write "magnesium sulfate"

Question 38

DO NOT USE: Potential Problem: Use instead:

Answer 38

Potential Problem: Use instead:

Question 39

DO NOT USE: Potential Problem: Use instead:

Answer 39

Potential Problem: Use instead:

Question 40

TALL MAN LETTERING: *highlights dissimilarities* - helps to reduce look alike sound alike medication errors - Look-alike, sound-alike medications are a common cause of medication errors - drugs that are easily mixed up should be labeled with TALL MAN LETTERS - TJC requires tall man lettering - ISMP list is considered the gold standard ex. CeleXA, CeleBREX prediSONE, prednisoLONE

Answer 40

** Using Tall MAN LETTERS, which mix upper- and lower-case letters, draws attention to the dissimilarities in the drug names. - the letters that are upper case are the ones that are different between the two look-alike sound-alike drugs. TALL

Question 41

Dug dictionaries within computer systems and automated dispensing cabinets (ADC) often have alerts that prompt the provider to confirm that the correct medication is being ordered or withdrawn. For example, a warning may appear on the screen of the ADC that will state: "This is DILAUDID. Did you want Hydromorphone?" to avoid confusion with morphine.

Question 42

High Alert Medications: - drugs with a heighted risk of causing significant patient harm if used in error should be designated as high-alert. High-alert medications can be used safety by developing protocols or order sets for use, using: - premixed products whenever possible - limiting concentrations available in the institution - stocking High-alert products only in the pharmacy Protocols for high-alert drugs increase appropriate prescribing and reduce the chance of errors from inappropriate prescribing.

Answer 42

The ISMP "High-Alert" list for acute care settings is available online. ISMP's list represents the most common agents that are high risk, but an institution's list may include additional drugs based on experience in that setting. [www.ismp.org] Safe Use Precautions: -------------------------------------------------------------------------------------------------------------------- - Protocols: baseline monitoring, scheduled labs, starting and max dose, exclusions to use, restricted access to drug. - Dispense by pharmacy (not from ADC); remove from floor stock - - - if High-Alert drugs go in ADC, THEN it is done a specific way - Use premixed products whenever possible - Special bins [e.g. Color coded] and labels - - - Any drug that is high-risk for significant harm if dispensed incorrectly can be placed in a medication bin that provides a visual alert to the person accessing the medication. - - - The bin can be labeled with warnings and include materials (placed inside the bin that should be dispensed with the drug (such as oral syringes or MedGuides).

Question 43

Select High Alert Medications: _________________________________________________________________________ - Anesthetics, inhaled or IV (e.g. propofol) - Antiarrhythmics, IV (e.g. amiodarone) - Anticoagulants/Antithrombotics (e.g. heparin, warfarin) - Chemotherapeutics (e.g. methotrexate) - Epidural/Intrathecal drugs - Hypertonic Saline (greater than 0.9% NaCl) - Immunosuppressants (e.g. cyclosporine) - Inotropics (e.g. digoxin) - Insulins (e.g. insulin aspart, insulin U-500) - Magnesium sulfate injection - Neuromuscular blocking agents (e.g. vecuronium) - Opioids - Oral hypoglycemics (e.g. sulfonylureas) - Parenteral nutrition - Potassium chloride and Phosphates for injection - Sterile water for injection

Answer 43

concentrated electrolytes - KCl, NaCl, magnesium, phosphate __________________________________________________________________________________

Question 44

Examples of Safe-Use Medications: Insulin: - Do NOT place insulin in automated dispensing cabinets (ADCs); all insulin orders should be reviewed by a pharmacist prior to dispensing. - Standardize all insulin infusions to one concentration - Develop protocols for insulin infusions, transition from infusion to SC and sliding scale orders; use standard orders for management of hypoglycemia - Do NOT Use "U" for units; ALWAYS label with "units" OR "units = mL," but NEVER just "mL'. - If U-500 is stocked, specify conditions under which it is to be used, which product will be stocked (vials and U-500 syringes vs. pens), and how doses will be supplied.

Answer 44

Examples of Safe-Use Medications: Potassium chloride (KCl): - Remove all KCl vials from floor stock; prepare all KCl infusions in the pharmacy - Use premixed containers - Use protocols for KCl delivery which include indications for IV administration, maximum rate of infusion, maximum allowable concentration, guidelines for when cardiac monitoring is required, a stipulation that all KCl infusions must be given via a pump, prohibition of multiple simultaneous KCl solutions (e.g. No IV KCl while KCl is being infused in another IV) - Allow for automatic substitution of oral KCl for IV KCl, when appropriate - Label all fluids containing potassium with a "Potassium Added" sticker

Answer 45

- Inadvertent administration of concentrated electrolyte - Check level at baseline, repeatedly - Limit the available concentrations of hypertonic saline - Standardize dosing and monitoring - Separate the solution from other fluids in controlled-access cabinets - Use color labeling, with oversight by pharmacists

Question 47

Medication Therapy Management (MTM): (CMR) Comprehensive medication review: (PMR) Personal Medication Record: (MAP) Medication-related Action Plan): Patients targeted for MTM most often: - have multiple chronic conditions - are taking multiple drugs and are likely to incur costs for covered drugs that exceed a predetermined level.

Answer 47

Computer databases are used to identify patients with certain high-risk conditions (such as heart failure or uncontrolled diabetes) and assign a pharmacist (preferably) to review profiles for proper medication use. - the pharmacist can form a partnership with the patient and prescriber to remedy any issues or lapses. Often these reviews identify missed therapy. For example, - lack of a ACE inhibitor or ARB in patients with diabetes and albuminuria - missing beta blocker therapy post MI - missing bisphosphonate therapy with high dose chronic steroids

Question 48

Medication Therapy Management: - Errors may be discovered during a MTR - a popular MTM initiative is to improve nonadherence in patients with heart failure due to the high rate of ED visits for decompensated heart failure. - MTM is also used to identify: - Cost Savings, by promoting switches to generics or more affordable brands, or by suggesting patient assistance programs or low-income subsidies for eligible members.

Answer 48

MTM encourages patients to be active participants in their health care, empowering them to be more knowledgeable about and responsible for their health and medication use. The patient-centered MTM program promotes collaboration between the pharmacist, patient and prescriber to optimize safe and effective medication use. The goal of this program is to optimize therapeutic outcomes by focusing on safety, effectiveness, lower-cost alternatives and adherence.

Question 50

Medication Reconciliation: involves COMPARING a patient's new medication orders to all of the medications that the patient has been taking at home (including OTC and dietary supplements). - this reconciliation is done to AVOID medication errors such as omissions, duplications, dosing errors or drug interactions during transitions of care. - medication reconciliation should be completed at EVERY "Transition of Care" in which new medications are ordered or existing orders are rewritten. (Transition of Care), includes: - changes in setting, service, practitioner or level of care. Common examples are hospital admission, transfer into or out of an ICU and hospital discharge. The medication reconciliation process comprises of 5 steps: 1. Develop a list of current medications 2. Develop a list of medications to be prescribed 3. Compare the medications on both lists 4. Note discrepancies and make clinical decisions based on the comparison 5. Communicate the new list to appropriate caregivers and to the patient.

Answer 50

- medication reconciliation ("med rec") is now usually performed within the electronic health record (EHC). - this process is most effective when complete and accurate information is entered into the patient's medical record. - For this reason, pharmacy departments are often actively involved in documenting home medication use and performing medication reconciliation. - In many hospitals, admission orders for a patient cannot be entered into the electronic system until medication reconciliation is completed by a prescriber, pharmacist, pharmacy technician or nurse.

Question 51

Medication Reconciliation: MED-REC Whenever a patient changes where they are located (e.g. comparing inpatient and outpatient) 1) Develop a list of current medications 2) Develop a list of medications to be taken in the new setting 3) Compare the 2 lists 4) Fix any discrepancies

Question 52

Indications and Proper Instructions on Prescriptions: - An indication for use written on the prescription (such as lisinopril 10mg once daily for hypertension) helps pharmacists ensure appropriate prescribing and drug selection. - Using the term "as directed" is NOT acceptable on prescriptions because the patient often has no idea what this means, AND the pharmacist cannot verify a proper dosing regimen.

Answer 52

- it would be preferable to write "use per instructions on the dosing calendar" since the patient may not understand hot to take the medication and may not be aware that a separate dosing calendar exists.

Question 53

Use of the Metric System: - measurements should be recorded using the metric system only* - prescribers should use metric units to express all weights and volumes. - computer systems generally have a drop-down menu for selecting the correct units (e.g. lb vs. kg) and easily converting between units.

Answer 53

Common Conversions: lbs ----------> kg feet & inches -------> meters & cm --------------------------------------------------------------------------------------------------------------------Measurements of length: Measurements of weight: Measurements of capacity/volume:

Question 54

Do NOT Identify Medications Based on Packaging alone: - Look-alike packaging can contribute to errors** - If unavoidable, separate look-alike drugs in the pharmacy and patient care units, or repackage** - NEVER rely on the package appearance (e.g. color, design) to identify the right drug product. - Pharmacies frequently have to purchase products from different manufacturers (and these may look vastly different).

Question 55

AVOID Multiple-Dose Vials: _____________________________________________________________________ - multiple dose vials pose a risk for cross-contamination (infection) and overdosing**. - If used, they should (ideally) be designated for a single patient and labeled appropriately**. - The remainder should be discarded when the medication is discontinued, or when the patient is discharged then discharge the remainder**.

Answer 55

ex. insulin pens, labeled for single patient use

Question 56

Safe Practices For Emergency Medications/Crash Carts: - Medications SHOULD be UNIT DOSE (e.g. contains a single dose) & AGE-specific, including pediatric-specific doses. - Sore in SEALED or LOCKED containers. - Monitor the drug EXPIRATION dates. - Trained pharmacists, SHOULD BE PRESENT AT CODES when possible.

Answer 56

Safe Practices For Emergency Medications/Crash Carts: - a quick reference with weight-based dosing (e.g. Broselow tape) should be placed in the trays used in the pediatric units. - If a unit dose medication is NOT available THEN it is best to have prefilled syringes and premixed drips in the cart (to the extent possible because it is easy to make a mistake under the stress of a code. - The emergency medications should be stored in sealed or locked containers in a locked room and replaced as soon as possible after use (through a CART EXCHANGE so that the area is not left without required medications)** - Drug expirations dates should be monitored. - Trained pharmacists should be present at codes when possible

Question 57

Code BLUE: Medical Emergency

Answer 57

- A code Blue refers to a patient requiring emergency medical care, typically for cardiac or respiratory arrest. The overhead announcement and/or paging system will provide the patient's location. The code team (often including a pharmacist) will rush to the room and begin immediate resuscitative efforts.

Question 58

Code Red: Fire or Smoke Code Orange: Evacuation Code Purple: Bomb Threat Code Black: Personal Threat Code Yellow: Internal Emergency Code Brown: External Emergency

Question 59

Dedicate Pharmacist's to High-Risk Areas:

Answer 59

Dedicate Pharmacist's to High-Risk Areas: - (ICUs) Intensive Care Units - pediatric units, (PICU) Pediatric Intensive Care Units, (NICU) Neonatal Intensive Care Unit - Emergency Departments These are Units with a high incidence of preventable medication errors. Pharmacists working in these units can assist in identifying and preventing medication errors by developing process improvements designed to reduce errors.

Question 60

Monitor For Drug-Food Interactions:

Answer 60

Monitor For Drug-Food Interactions: - Check for Drug-Food Interactions routinely and involve the nutrition department (also called "dietary") when the profile includes drugs with a HIGH RATE of food Interactions. (e.g. warfarin) Or medications that interact with ENTERAL FEEDINGS (i.e. tube feedings) - For example, Phenytoin administration via feeding tube requires that enteral feedings be held for 1-2 hours before and after the dose.

Question 61

Education: - Staff - Patients

Answer 61

Education: - Staff education Programs such as "In-services" SHOULD be provided whenever new high-alert drugs are being used in the facility, to introduce new guidelines and procedural changes aimed at preventing medication errors. - The information provided in these "in-services" should be unbiased and should NOT be provided in a skewed manner by drug company representatives. - Many hospitals now limit access of pharmaceutical companies and representatives due to inherent bias. ---------------------------------------------------------------------------------------------------- - Patients can play a vital role in preventing medication errors when they have been encouraged to ask questions and seek satisfactory answers about their medications before drugs are dispensed at a pharmacy. - If a patient questions any part of the medication dispensing process, whether it is about the drug's appearance, dose or something else, the pharmacist must be receptive and responsive (not defensive) - All patient inquiries should be thoroughly investigated before the medication is dispensed. The written information about the medication should be at a reading level that is appropriate for the patient. - It MAY BE NECESSARY to provide pictures or other means of instruction to patients who do NOT speak English or are unable to read English. - ATTEMPTS must be made to communicate to the patient in THEIR LANGUAGE, USING ON-SITE staff or DIAL-IN translation services.

Question 63

Five Rights of Medication Administration: - these are a quick double-check that should be performed by a healthcare professional every time a medication is administered. - they ARE AN EXAMPLE of BEST practice in MEDICATION SAFTEY that helps prevent medication errors but must be combined with other system-based error prevention methods. - Barcoding: is an example of this technological tool that has been implemented in medication administration to assist in ensuring the "five rights". 1) 2) 3) 4) 5)

Answer 63

1) The RIGHT Patient 2) The Right Drug 3) The Right Time and Frequency 4) The Right Dose 5) The Right Route

Question 64

Use of technology & automated systems: - (CPOE)- Computerized Prescribing Order Entry: is a process that allows DIRECT ENTRY of medical orders by prescribers into the computer system. This has benefit of reducing errors by minimizing the ambiguity resulting from handwritten orders. A much greater benefit is seen with the COMBINATION of CPOE and CLINICAL DECISION SUPPORT (CDS) tools. - Decision support functionality - - Clinical guidelines and patient labs can be built into the CPOE system, and ALERTS can NOTIFY a prescriber if the drug is inappropriate, or if labs indicate that the drug could be unsafe (such as a high potassium level and a new order for a potassium sparring agent). - - - For example, one of ISMPs best practice recommendations is to program the computer system to automatically select a weekly frequency for oral methotrexate orders, TO PREVENT an accidental selection of daily dosing. - - - (CPOE) can include standard order sets and protocols. For example, an alert will populate whenever a prescriber attempts to order Citalopram with a dose greater than 40mg/day. - Barcoding - ADCs

Answer 64

- the integration of healthcare knowledge with technology and automation is called PHARMACY INFORMATICS. - In most institutions, pharmacists are actively involved in creating, monitoring and improving use of tools.

Question 65

Use of technology & automated systems: - BARCODING: The barcode follows the drug through the MEDICATION-USE PROCESS to make sure it is properly stocked (such as in the right space in the pharmacy or in the right pocket in the dispensing cabinet), through compounding (if required) AND ADMINISTRATION TO THE right patient. It also helps to PREVENT DIVERSION of drugs that are commonly abused. - the barcode is used at the bedside to identify that the CORRECT DRUG (by scanning the barcode on the drug's packaging) is going to the RIGHT PATIENT (by scanning the barcode on the patient's wristband) and confirms that the dose is being given at the RIGHT TIME by matching to the order in the system. - Barcodes are now on many infusion pumps and can prevent errors involving medications being given IV. This includes identifying drugs that are not meant to be administered via this route, AUTO-PROGRAMMING (which pulls infusion parameters from the electronic health record) and AUTO-DOCUMENTATION (which records dose/rate changes for confirmation).

Answer 65

Barcoding, may be the most important medication error reduction tool currently available. The nurse is often signed into the medical record (or scans the barcode on their name tag) while barcode scanning, which records who administered the dose.

Question 66

Use of technology & automated systems: - (ADCs) Automated Dispensing Cabinets: Practical Benefits of ADCs- - drug inventory and medication replacement can be automated when drugs are placed into the cabinet and removed. - provide enhanced security of controlled drugs by recording detailed information about transcripts (e.g. who gained access to the controlled medications). - the drugs are easily available at the unit and do not require individual delivery from the pharmacy. - permit barcoding and provide alerts and usage reports.

Answer 66

Common names of ADCs: - Pyxis - Omnicell - ScriptPro - Accudose -Acute Care sites such as patient care floors, operating rooms and surgery centers, intensive care units and the emergency department. - Non-acute care sites such as skilled nursing facilities, rehabilitation centers, and clinics.

Question 67

Use of technology & automated systems: (ADCs) Automated Dispensing Cabinets: Methods To Improve ADC Safety- - TJC REQUIRES that a pharmacist review the order before the medication can be removed from the ADC for a patient, EXCEPT in special circumstances (an override). The override function should be LIMITED to a select list of medications. Overrides for medications used for reversal of adverse events (e.g. naloxone, flumazenil) should be investigated. - The Most Common ERROR associated with ADC use is giving the WRONG DRUG or DOSE to a patient. The patients MAR should be accessible to practitioners while they are removing medications from the ADC. The use of BARCODE SCANNING IMPROVES ADC SAFETY. - LOOK-ALIKE, SOUND-ALIKE MEDICATIONS SHOULD be stored in different locations within the ADC. Using computerized alerts can help reduce error risk (e.g. require confirmation when selecting drugs with high potential for mix-up. - Certain medications SHOULD NOT be put in the ADCs including: - INSULINS - WARFARIN - HIGH- DOSE NARCOTICS (such as hydromorphone 10mg/mL and morphine 25mg/mL) - Nurses SHOULD NOT BE PERMITTED (allowed) to put medications back into the medication compartment because they might be placed in the wrong area; it is best to have a separate drawer for all "returned" medications. - IT THE MACHINE IS IN A BUSY, NOISEY ENVIRONMENT, OR IN ONE WITH POOR LIGHTING, ERRORS INCREASE.

Question 68

Patient Controlled Analgesia Devices: - Opioids are effective medications for moderate to severe post-surgical pain. They may be administered with patient-controlled analgesia (PCA) devices, where the patient can self-administer doses of medication with the push of a button. The dose and dose limits are ordered by the physician. - The PCA device will NOT allow the patient to take more medication than ordered. - PCAs allow the patient to treat pain quickly (there is no need to call the nurse and wait for the dose to arrive) and allow the administration of small doses, which helps reduce side effects (particularly oversedation). - PCA drug delivery can mimic the pain pattern more closely and provide good pain control. - PCAs can be administered with anesthetics for a synergistic benefit in pain relief.

Answer 68

Patient Controlled Analgesia Devices:

Question 69

Patient Controlled Analgesia Devices: PCA Safety Considerations: - the device can be complex and require setup and programming. This is a significant cause of preventable medication errors. PCAs should be used only by well-coordinated healthcare teams. - patients MAY NOT be appropriate candidates for PCA treatment. They should be cooperative and should have a cognitive assessment prior to using the PCA to ensure that they can follow instructions. - friends and family members SHOULD NOT administer PCA doses. THIS IS A TJC REQUIREMENT* - PCAs DO NOT frequently cause respiratory depression, but the risk is present. Advanced age, obesity and concurrent use of CNS depressants (in addition to higher opioid doses) increase the risk. - Assess the patients pain, sedation and respiratory rate on a scheduled basis

Answer 69

Patient Controlled Analgesia Devices: Safety Steps: - Limit the opioids available in floor stock/outside of ADCs. - Use standard order sets (set drug dosages, especially for opioid naive patients) so that safe doses of drugs are selected. - Educate staff about HYDROmorphone and morphine mix-ups - Implement PCA protocols that include independent double checking of the drug, pump setting and dosage. - Double check the drug, pump settings and dosage - - The concentration on the MAR should match the PCA label. - USE BARCODING TECHNOLOGY. Scanning the barcode on the PCA would help ensure the correct concentration is entered during PCA programming. It will also ensure that the right patient is getting the medication. - Assess the patient's pain, sedation and respiratory rate on a scheduled basis. "when we are monitoring opioids, remember sedation comes before respiratory depression, so we are monitoring sedation scales and respiratory rate because it slows down"

Question 71

Infection Control In Hospitals: - Hospitals are dangerous places - bad bugs hang out in hospitals - Most Hospital acquired (nosocomial) infections are preventable ------------------------------------------------------------------------------------------------------ - Presence of microorganisms in hospital environment - Immunocompromised patients - Transmission of pathogens between staff and patients and among patients

Answer 71

- Hospitals Infections cause avoidable illness and death and add enormous financial costs. - Many of these infections are preventable if proper techniques are followed - Medicare can refuse reimbursement for hospital acquired infections that are largely avoidable - Organisms that spread via surface contact include VRE, C.difficile, norovirus, and other intestinal tract infections.

Question 72

Infection Control In Hospitals: Common Typer of Hospital-Acquired (Nosocomial) Infections- - Urinary Tract Infections, from indwelling catheters (very common), *remove the catheter as soon as possible*- preventing catheter associated infections is ONE of TJCs NPSGs (National Patient Safety Goals). - Blood stream infections from IV lines (*central lines have the highest risk*) and catheters - Surgical site infections - decubitus ulcers - hepatitis - *clostridium difficile*, other GI infections - *pneumonia* (mostly due to ventilator use*), bronchitis 

Answer 72

- have to insert catheter with aseptic technique - remove catheter asap, colonizes with organisms

Question 73

Infection Control In Hospitals: Universal Precautions To Prevent Transmission: - Contact - Droplet - Airborne

Answer 73

Universal Precautions To Prevent Transmission: - - is an approach to infection control that treats human blood and bodily fluids as if they are infectious with HIV, HBV, and other bloodborne pathogens. - contact with bodily fluids should be avoided by wearing gloves, performing good hand hygiene and, in select cases, the use of gowns, masks or patient isolation. - there are 3 categories of transmission-based precautions defined by the CDC

Question 74

Infection Control In Hospitals: Universal Precautions To Prevent Transmission (CONTACT): - - Intended to prevent transmission of infectious agents which are spread by INDIRECT AND DIRECT contact with the patient and the patient's environment. - - Single patient rooms preferred. If not available, keep greater or equal to > 3 feet spatial separation between beds to prevent inadvertent sharing of items between patients. - - Healthcare personnel caring for these patients wear a GOWN AND GLOVES for all interactions that may involve contact with the patient or contaminated areas in the patients room. - **- Contact Precautions are Recommended for patients colonized or infected with MRSA & VRE & patients WITH C.difficile infection.

Answer 74

C.dif transmitted by spores.

Question 75

Infection Control In Hospitals: Universal Precautions To Prevent Transmission (DROPLET): - - Intended to prevent transmission of pathogens spread through close respiratory contact with respiratory secretions. - -Single patient rooms preferred. If not available, keep greater or equal to > 3 feet spatial separation and drawing a curtain between beds is especially important for disease transmitted via droplets. - - Healthcare personnel wear a mask (a respirator is not necessary) for close contact with the patient. The mask is DONNED UPON ENTRY to the patients room. - - Droplet precautions are recommended for patients with active B. PERTUSSIS, INFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS (RSV), ADENOVIRUS, RHINOVIRUS, N. MENINGITIDIS, and GROUP A STREPTOCOCCUS (for the first 24 hours of antimicrobial therapy).

Question 76

Infection Control In Hospitals: Universal Precautions To Prevent Transmission (AIRBORNE): - - Intended to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air - - Patient should be placed in an airborne infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with special air and ventilation handling pressure rooms. The AIR IS EXHAUSTED DIRECTLY TO THE OUTSIDE OR recirculated through HEPA filtration before return. - - Healthcare personnel wear a mask or respirator (N95 level or higher), depending on the disease, which IS DONNED PRIOR TO ROOM ENTRY. - - Airborne precautions ARE RECOMMENDED for patients with ACTIVE PULMONARY TUBERCULOSIS, MEASLES OR VARICELLA VIRUS (chicken pox).

Answer 76

think about the airflow for that room. The air shouldn't be coming out at you upon room entry. Will contaminate air in other adjacent rooms.

Question 77

Catheter-related Bloodstream Infections: - - the most important and cost-effective strategy to minimize catheter-related bloodstream infections (CRMSI) is use of aseptic technique during catheter insertion, including proper handwashing and utilization of standard protocols/catheter insertion checklist. - - it is also important to minimize use of intravascular catheters, if possible, through intravenous to oral route conversion protocols and setting appropriate time limits for catheter use. For example, peripheral catheters should be removed/replaced every 2-3 days to minimize risk of infection. - - Other strategies shown to reduce risk of (CRBSI) Catheter-Related BloodStream Infections include: - - the use of skin antiseptics (2% chlorhexidine), antibiotic impregnated central venous catheters and antibiotic/ethanol lock therapy, but use must be weighed against the potential risk for increased rates of resistance.

Question 78

Hand Hygiene: - - studies show hand hygiene by those working in healthcare settings reduces the spread of nosocomial infections - ALCOHOL-BASED hand rubs (gel, rinse or foam) are CONSIDERED MORE EFFECTIVE in the healthcare setting than plain soap or antimicrobial soap and water, but soap and water are preferable in some situations. - fingernails should be clipped short, and no jewelry should be worn under gloves (this can harbor bacteria and tear the gloves. - ANTIMICROBIAL HAND SOAP that contain chlorhexidine (Hibiclens) may be preferable to reduce infections in healthcare facilities. Triclosan, an antibacterial, may also be beneficial, but this compound gets into the water supply and has environmental concerns.

Question 79

When to Perform Hand Hygiene: Your 5 moments FOR Hand Hygiene - 1- Before patient Contact 2- Before Aseptic Task 3- After Body Fluid Exposure Risk 4- After Patient Contact 5- After Contact With Patient Surroundings

Answer 79

Alcohol-rub or Wash before and after EVERY contact. ---------------------------------------------------------------------------------------------------------------- - Before entering and after leaving patient rooms and between patient contacts if there is more than one patient per room - Before donning and after removing gloves (Use New Gloves with each patient) - Before handling invasive devices, including injections - After coughing or sneezing - Before handling food and oral medications

Question 80

Use Soap and Water [NOT Alcohol-Based Rubs in These SITUATIONS]: - - Before eating - After using the restroom - Anytime there is visible soil (anything noticeable on the hands). - After caring for a patient with diarrhea or known C.difficile or spore-forming organisms; ALCOHOL-BASED hand rubs have POOR ACTIVITY against spores. Handwashing physically removes spores. - Before caring for patients with food allergies.

Answer 80

SOAP and WATER Technique: - - Wet both sides of hands, apply soap, rub together for at least 15 seconds - Rinse thoroughly - Dry with paper towel and use the towel to turn off the water

Question 81

ALCOHOL-BASED Hand Rubs Technique: - - Use enough gel (2-5 mL or about the size of a quarter). - Rub hands together until the gel dries (15-25 seconds) - Hands should be completely dry before putting on gloves.

Question 82

Hand Hygiene for Sterile Compounding:

Question 83

Safe Injection Practices: SHARPS DISPOSAL

Answer 83

Sharps Containers Have a Fill line*

Question 84

Safe Injection Practices:

Question 85

Safe Injection Practices:

Question 86

Safe Injection Practices: