Building a Safe Medication Management System Flashcards
what does a sentinel event trigger
a root cause analysis by the JC
FDA
dictate safety and efficacy for intended use, dispensing
state laws regulate
pharmacists
DOPL
licensing, should not steal med pad
to err is human highlighted
med error
leapfrog
ceo leverage influence to advance pt safety in medication
JC included med error in
NPSG
tracer methology
JC chooses pt to follow from admission and discharge, what happens
many ADEs are
preventable
antibiotics are
overprescribed, pt expect to leave clinic with prescription
talk w pt that med is not needed
med error
no uniform definition
any preventable event that can lead to pt harm
medication w/o harm
aim to reduce severe avoidable mediciation errors
reconciliation
what med did pt come in with, and what med they leave with
most proximal error of medication usage?
lack of knowledge about the drug
ADE
error of omission (didn’t give) or commission
transition of care
well documented source of preventable harm
types of med errors
admin error - incorrect route of admin, wrong dose/pt
monitoring error - failing to consider pt entire condition, allergy, or potential drug combo interaction
compliance error - not following protocol for dispensing medication
common sys failures include
inaccurate order transcription
drug knowledge dissemination
failing to obtain allergy history
poor communication
unavailable medication
where to report drugs
FDA MedWatchA
AHRQ strategies to prevent ADES
prescribing - be conservative
transcribing- on the decline, mostly electronic
dispensing - avoiding mistaking med for each other
administration - barcode, minimize interruption
performance tracking - PDMP
pharmacies can tell if pt is getting med from other doctors/pharmacies, avoid exploitation
PQA- pharmacy quality alliance
track information on med safety, adherence, use
CMS star rating programs- high stakes
reimbursement tied to performance on quality metrics
pharmacists
dispensing role in HC,
MTM focuses on
Medication therapy review
Pharmacotherapy consults
Anticoagulation
management
Immunizations
Heath and wellness programs
med errors are reported
voluntarily, so underreported
risk factors that cause adverse med errors
work is busy, lack of literacy, many med similarities
med management
prep and dispense med
amin med
monitor med effects
states are required to monitor drug usage for medicaid pts
step 1- select and procure medication
maintain formulary annually (safe and effective)
(inventory of all their common medications)
if you bring med to hospital
give it to them, so they can track it
drug pedigree
chain of custody of drug from manufacturer to pharmacy
step 2: properly store med
prevent unauthorized access, double locked sotrage
step 3: prescribe and transcribe med
acceptable use of verbal orders,
read back- ensure you heard the order correctly
can’t use abbreviations when ordering certain med- JC
step 4: dispense med
pharmacist review each prescription or med order for appropriateness
prevent prescribing, admin, and pharmacy errors
standardized labeling
keep in package until admin
step 5 admin med
two pt identifier prior admin, unit dose sys, six rights
six rights of med admin
Right patient
Right medication
Right dose
Right time
Right route
Right documentation
+ Right to Refuse
step 6- monitor med effects
monitor first dose of med, gather pt perceptions, process in place to deal with Ade
step 7: evaluate med manage sys
analyze med error or near misses with committee
drug diversion
removal of med from its usual stream of prep, dispensing, and admin by personnel involved in those steps to sell med in nonhealthcare setting
drug diversion results in
outbreak of ID, increased ED visits, death, avoidable expenditures, lost productivity
FMEA- failure mode and effect analysis
proactive tool to analyze potential problems when introducing new sys or exiting process,
includes defining high risk process using flow charts
freq of failure
potential harm
likelihood failure will be detected before it reaches pt
