05- Medication Safety Flashcards
Medication Error
Any preventable adverse drug event involving inappropriate medication use by a patient or health care professional; it may or may not cause the patient harm.
Adverse Drug Event
Any event of injury/harm from using a drug or the lack of use of a drug. An error may or may not have occurred.
Adverse Drug Reaction
Any type of ADE that occurs at NORMAL doses, resulting in an unexpected reaction to a medication. Includes side effects & allergies.
Vanessa’s Law
Mandated reporting of ADR to Health Canada (drug is recalled).
Near Miss
Medication errors that are stopped before harm can occur to patient - error is cauught beforehand. Is a potential ADE (error has the potential to cause harm).
T or F: Medication errors can occur when prescribing, transcribing, dispensing, administering & monitoring.
true
Most medication errors occur during which 2 processess?
Prescribing & administering
Swiss Cheese Model
Shows that errors can bypass lines of defense to reach the patient. There may be multiple levels of defense, but latent conditions such as poor design, procedures, management decisions, etc allows for active errors that can compromise the patient’s safety.
Errors are to be expected even in the best opportunities & the holes (latent conditions) represent opportunities for the process to fail.
What are some human/environmental factors that contribute to med errors?
- poor lighting
- fatigue
- stress
- distractions
- messy work area
High alert medications
Medications that have a high risk of causing patient harm when used in error. Includes heparin & concentrated electrolytes.
What are the 8 rights?
- Patient
- Med
- Reason
- Dose
- Frequency
- Route
- Site
- Time
When a medication is ordered to be on hold, the order should have what 2 things?
- Reason for hold
2. Restart date/time OR reassessment date/time
Narcotics & controlled substances are…
- high risk meds
- can have serious consequences
- are prone to misuse
- must be wasted in irretrievable containers
Which drug is stronger: morphine or hydromorphone? By how much?
Hydromorphone; is 5x stronger (bc it has 5 more letters)
T or F: You should compare the patient’s medications at admission, transfer, dischange, with what the organization is providing in order to avoid errors.
true
Institution IV Monographs
Provides information on IV drug (reconstitution, how to administer, monitoring parameters, IV solution compatibility, etc.)
What are IV guardrails?
- min & max limits
- makes sure IV drug is at the right dose, not running too fast & is not overly concentrated
When should you use IV guardrails?
For all IV meds, IV infusions, TPN
What is methadone?
A long acting opioid
What is naloxone?
Antidote for opioid overdose
Why is medication safety important?
- Its a frequent problem (1 med error per hospitalized patient per day)
- We end up using a lot of health care resources in treatment of drug overdoses
- Its a major cause of death (7000 per year)
- Its very costly ($3.5 billion spent each year on extra medical costs associated with adverse drug events)
- Preventable (1.5 million preventable events each year)
What part of medication safety is the nurses responsibility?
- Ensuring the order is complete, appropriate and clear
What is a medication error?
- Preventable
- Event that may cause or lead to inappropriate medication use or patient harm
What is an example of a medication error?
Physician prescribes amoxicillin to a patient with a history of anaphylactic reaction to penicillin. The patient takes the amoxicillin which results in a severe reaction requiring hospitalization
What is an adverse drug event?
Harm resulting from medication or lack of medication (error may or may not have occurred)
What is an example of an adverse drug event?
Patient with depression overdoses on amitriptyline (anti-depressant)
