Prevent & Manage Med Errors Flashcards Preview

OU Management Spring 2018 > Prevent & Manage Med Errors > Flashcards

Flashcards in Prevent & Manage Med Errors Deck (17)
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1
Q

Describe systems thinking perspective.

A
  • discipline for seeing wholes
  • framework for seeing interrelationships, patterns of change
  • sensibility – for the subtle interconnectedness that gives living systems their unique character
2
Q

Front end errors

A
  • Focus on front-line practitioner
  • Assign blame
  • Punitive action
  • Prevention by changing people and their behaviors
3
Q

Latent errors

A
- Focus on weaknesses in
organizational structure
- Prevention by improving the system
- For example: 
• Ineffective personnel training 
•  Incomplete patient information 
•  Unclear communication of a drug order 
•  Lack of independent double-check before dispensing
4
Q

What are system-based causes of medication errors? (not an objective)

A
  • Patient information
  • Drug information
  • Communication of drug information
  • Drug storage, stock, and distribution
  • Environmental factors
  • Staff competency and education
  • Patient education
  • Quality processes and risk management
5
Q

Identify common causes of errors associated with ordering medications

A
  • Illegible handwriting
  • Look-alike, sound-alike drug names
  • Abbreviations
  • Ambiguous orders
  • e-Prescribing
6
Q

Strategies to minimize errors with illegible handwriting

A
  • Block letters
  • Indication
  • Computerized physician order entry
  • Pre-printed orders
  • Multi-stage checks
7
Q

Strategies to minimize errors with look-alike drug names

A
  • Read back
  • Spell drug name
  • Tall man lettering
8
Q

Strategies to minimize errors with abbreviations

A

Avoid the following:

  • U for “units” D/C
  • Q for “every” (QD, QID, QOD, qd, qid, qod)
  • MgSO4 (Mg) and MSO4 (MS)
  • MTX
  • AZT
  • HCT and HCTZ
9
Q

Strategies to minimize errors with ambiguous orders

A
  • be careful with zeroes and decimal points
  • specify strengths
  • use fractions and not slashes because it can be mistaken for a 1
  • use both mg and mL for liquids
  • order with proper unit expression
  • have proper spacing
10
Q

How does e-prescribing errors happen?

A
  • Memorize parts of e-prescriptions
  • Perform dosage calculations mentally
  • Communication issues with prescribers and patients
11
Q

What are things that could go wrong with e-prescriptions?

A

Wrong:

  • drug quantity
  • dosing directions
  • duration of therapy
  • dosage formulation
  • drug class
12
Q

Identify common causes of errors associated pharmacist handoffs.

A
  • Overload
  • Underload
  • Scatter
  • Conflict
  • Erroneous
13
Q

Identify strategies to reduce errors associated with preparing / dispensing medications

A
  • Read label three times: when product is selected, when it is prepared, when it is returned back on the shelf or disposed of
  • Separate drugs with similar-sounding names
  • Change appearances of certain drug names
14
Q

With patient education and counseling, what are outcome of error-prevention efforts influenced by?

A
  • Direct patient education
  • Health literacy
  • Patient compliance
15
Q

Identify strategies to reduce errors associated with counseling / educating patients.

A
  • State laws for mandatory counseling

- Private area for Rx pick-up

16
Q

Explain the important of health literacy (not an objective)

A
  • Approximately one-third of U.S. adults have limited health literacy
  • Have difficulty reading and understanding medication instructions and information
  • Hesitant to ask questions
17
Q

Identify some medication error reduction strategies

A
  • Fail-safes & constraints (system change; no KCl on floor)
  • Forcing functions (hard stop; wt before heparin; bar codes)
  • Automation and computerization (e-prescribing)
  • Standardization (pre-printed Rx pads, standard order forms)
  • Redundancies (duplicate steps, patient counseling)
  • Reminders & checklists (auxiliary labels, LASA med alerts)
  • Rules and policies
  • Education and information
  • Suggestions to be more careful or vigilant