`Y1 Patient Safety

Question 1

Drug related problems (DRP):

Answer 1

Drug related problems (DRP): “an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes”

Question 2

Adverse drug events (ADE):

Answer 2

Adverse drug events (ADE): “any harm relating to the use of medication”

Question 3

Medication errors:

Answer 3

Medication errors: “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”

Question 4

Adverse drug reactions (ADR):

Answer 4

Adverse drug reactions (ADR): unpredictable harmful or unpleasant reaction to a drug at a routine dose

Question 5

medication administration error

Answer 5

medication administration error is any deviation from the written prescription or medication order, or from standard organisational policy or the manufacturer’s instructions.”

Question 6

Prescribing error

Answer 6

Prescribing error: because of a prescribing decision or prescription writing process, there is an unintentional significant reduction in the probability of treatment being timely & effective or increase in the risk of harm when compared with generally accepted practice.

Question 7

Dispensing error

Answer 7

Dispensing error: Any unintended deviation among the dispensed drugs in comparison with the written medical prescription or medication order

Question 8

5 Rs of medication safety

Answer 8

1. Right drug
2. Right route
3. Right time
4. Right dose
5. Right patient

Question 9

Mistake, Slips, Lapse & Violation

Answer 9

Mistakes – wrong decisions – doing the wrong thing but believing it to be right. Can be based on applying the wrong knowledge or rule to a situation
Slips – not doing what you’re meant to do, e.g. too much or too little of something
Lapses – forgetting to do something
Violation – deliberate – either because the situation forced it, or intentionally

Question 10

Risk management

Answer 10

The decisions we make and carry out that aim to minimise the adverse effects of accidental losses (errors) have on an organisation

Question 11

NHS Never Events

Answer 11

Serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations

Question 12

Root Cause Analysis (RCA) & the 6 steps

Answer 12

A structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it.
There are 6 steps in an RCA:
1. Gathering information about an incident
2. Mapping the information
3. Identifying problems
4. Analysing contributory factors
5. Determining root causes
6. Developing recommendations and implementing solutions.

Question 13

Failure Modes and Effects Analysis (FMEA)

Answer 13

A systematic method, carried out by teams used to identify and prevent process errors and product problems before they occur
There are 6 steps in an FMEA
1. Graphically describe the process
2. Identify failure modes
3. List failure modes
4. Design interventions for failure modes
5. Identify outcome measures for interventions
6. Implement and monitor interventions

Question 14

Strengths & weaknesses of FMEA

Answer 14

Strengths:
- Proactive
- Detailed & invites people to consider factors possibly causing errors
- Systematic
- Emphasises team involvement
- Ratings can be useful in helping teams identify where to start

Weakness:
- Ratings of severity, probability & detectability are unreliable if not done by someone experienced
- Different teams won’t always produce the same analysis
- Very time consuming
- Less guidance on interventions