Ch. 7 Medication Safety & Quality Improvement Flashcards
Sentinel Event
Unexpected occurrence involving death or serious physical or psychological injury, or risk thereof
Response to medical errors
Internal notification External Reporting Disclosure Investigation Improvement
Errors of Omission
Something was LEFT OUT that is needed for safety
Ex. Failure to warn a pt about an important SE with a new medication
Error of Comission
Something was done INCORRECTLY
Ex. Prescribing bupropion to a pt with a hx of seizures
In the community setting, errors should be reported to:
The corporate office or the owner (if independent)
In the hospital setting, errors should be reported to:
The hospital’s specific medication event reporting system, as well as the P&T committee and Medication Safety Committee
Root Cause Analysis (RCA)
Is a retrospective investigation of an event that has already occurred
Failure Mode and Effects Analysis (FMEA)
Is an analysis that is done prospectively to identify pathways that could lead to errors and to identify ways to reduce the error risk. A proactive method
Joint Commission visits accredited institutions every:
3 years
The 6 main National Patient Safety Goals include:
Label all medication on and off the sterile field
Reduce harm associated with anticoagulant therapy
Maintain and communicate accurate patient medical information
Report critical results (labs and diagnostic) on timely basis
Comply with CDC hand hygiene guidelines
Reduce healthcare associated infections
Medication errors should be reported within:
48 hours
NPSG 01.01.01: How many patient identifiers should be checked when providing care?
At least two patient identifiers
NPSG 03.06.01: What types of communication should be performed/communicated accurately?
Medication reconciliation and discharge counseling
NPSG 03.05.01: What are some important elements to reduce the likelihood of harm associated with anticoagulant therapy?
Using standardized protocols (including baseline INR, frequency of INR monitoring and monitoring for bleeding and HIT) Inform dietary program
Programmable pumps for heparin
Provide education to patients and families
NPSG 03.06.01, 07.04.01, 07.05.01, 07.06.01: Implementing evidence-based practices to reduce healthcare associated infections includes:
Reducing MDR pathogens (such as MRSA, C diff, VRE and gram-negative bacteria) by addressing central lines, catheter-associated urinary tract infections, bloodstream infections and post-surgical infections
