QI

Question 1

What is the failure to complete a planned action as intended, or the use of a wrong plan to achieve an aim?

Answer 1

Medical Error

Question 2

What is the most common type of medical error?

Answer 2

Medication Error

Question 3

What are some examples of medication errors?

Answer 3

1. Ordering
2. Transmission of escripts
3. Preparing/Labeling/Administering the medication

Question 4

Name 7 ways you can reduce medication error

Answer 4

1. ID current meds (including OTC/Herbals)
2. Keeping allergies up to date
3. Neat handwriting
4. Avoid abbreviations
5. Accurate weight
6. No zeros after a number (okay if before- i.e. 0.3 okay, 3.0 not okay)
7. Include diagnosis, especially for drugs that sound alike

Question 5

What is an injury caused by medical management (versus underlying disease or condition)?

Answer 5

Adverse event

Question 6

What type of error causes harm to the patient?

Answer 6

Adverse event

Question 7

True or False: Most medical errors don’t lead to an adverse event

Answer 7

True

Question 8

What is an injury resulting from the use of a drug?

Answer 8

Adverse drug event

Question 9

True or False: Most adverse drug events don’t result from a medication error

Answer 9

True

*May result from medication error, but most don’t (like an unforeseen drug reaction)

Question 10

What is a response to a drug which is harmful and unintended?

Answer 10

Adverse drug reaction

Question 11

True or False: In order for an event to be considered an adverse drug reaction, dosing has to be appropriate for the situation

Answer 11

True

Question 12

True or False: A side effect is considered an adverse drug reaction

Answer 12

True

Question 13

What is a specific type of adverse drug reaction mediated by an immune response

Answer 13

Allergic reaction

Question 14

What is a situation where a medical error places a patient at risk for injury without actually resulting in injury?

Answer 14

Near miss event

Question 15

Name 2 situations that would be considered to be near miss events

Answer 15

1. Intercepted

2. Non-intercepted

Question 16

What type of error is noted before it gets to the patient?

Answer 16

Intercepted error

For all intents and purposes, it never happened

Question 17

What is an error that reaches the patient?

Answer 17

Non-intercepted error

Question 18

True or False: A non-intercepted error may or may not cause injury

Answer 18

True

Question 19

What describes an actual or potential death or serious injury as a result of medical care?

Answer 19

Sentinel Event

Question 20

True or False: Sentinel events are the result of medical errors

Answer 20

False- Not all are

Question 21

The risk for ADE’s is how many times higher in hospitalized children than adults?

Answer 21

3

Question 22

What is a common cause of dosing error for medications in children?

Answer 22

Compounding adult prepackaged medications for children

Question 23

What two home factors should you consider for a patient with an adverse drug reaction?

Answer 23

1. Guardians who don’t speak English well

2. Using home folk/traditional remedies (interact with a prescribed medication)

Question 24

Adverse events occur in what % of pediatric hospitalizations?

Answer 24

1%

Question 25

What % of adverse events in pediatric hospitalizations are preventable?

Answer 25

60%

Question 26

Why are ADE rates rising?

Answer 26

Possibly increase ability to detect rather than an actual increase in the incidence of these events

Question 27

What is the estimated cost of medical errors in the US?

Answer 27

37 billion/year

Question 28

True or False: Medicare/Medicaid are beginning to not reimburse to correct medical errors that increase length of stay

Answer 28

True

Question 29

Name 4 barriers to reporting medical errors

Answer 29

1. Not wanting to be blamed
2. Not wanting to appear incompetent
3. Not wanting to be the whistleblower
4. Fear of litigation

Question 30

True or False: Randomly auditing charts for medical errors would waste resources and is likely unhelpful

Answer 30

True

Question 31

What is “triggering”

Answer 31

Smoking gun technique- Example is to audit charts where a sedative reversal agent was used to ID an adverse drug event involving sedatives

Question 32

What is a trend whose goal is to increase reporting for the common good?

Answer 32

Blameless reporting

Question 33

What are 3 strategies to help with providers reporting medical errors?

Answer 33

1. Blameless reporting
2. Immunity (in terms of litigation)
3. Counseling/Debriefing services

Question 34

What are 4 things to remember when disclosing an error to a patient’s family?

Answer 34

1. Be totally transparent
2. Disclose why it happened
3. Explain how it will impact them
4. Explain what steps are being taken to prevent such an error from happening again

Question 35

True or False: Disclosing errors to families has been shown to reduce litigation and decrease settlement amounts

Answer 35

True

Question 36

True or False: You should apologize to a patients family when disclosing an error?

Answer 36

True

*Movement towards apologies being prevented from use in legal proceedings

Question 37

What are 2 things institutions are now providing for physicians when medical errors occur?

Answer 37

1. Suspending judgement of competence

2. Providing support via debriefing

Question 38

Name 5 ways that computers help to reduce medication errors

Answer 38

1. Eliminate handwriting issues
2. Weight-base calculators
3. Errors messages with overdose alarms
4. Alerts for drug interactions
5. Alerts of drug contraindications (based on diagnosis)

Question 39

Name two provider-based strategies to help reduce medication errors

Answer 39

1. Pharmacist on inpatient rounds

2. Request order reviews by pediatric pharmacists