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Law And Ethics > Errors > Flashcards

Errors Flashcards

1
Q

What are 3 common types of errors in pharmacy practice ?

A
  • Selection errors
  • Labelling errors
  • Bagging errors
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2
Q

What are some causes of errors in pharmacy?

A
  • Misreading the prescription
  • Similar drug names
  • Selecting the previous drug or dose from the patient’s medication record on the pharmacy computer
  • Similar packaging
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3
Q

Why is medication use considered a complex process?

A
  • involves multiple steps and people throughout the process
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4
Q

What does Reason’s Swiss Cheese Model explain about errors in medication use?

A
  • errors often occur due to multiple failings across the process, with weaknesses or holes in various stages aligning to cause an error
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5
Q

What are some factors that contribute to prescribing errors?

A
  • Therapeutic training
  • Drug knowledge and experience
  • Knowledge of the patient
  • Knowledge of risk
  • Physical and emotional health
  • Patient characteristics
  • Communication
  • Workload and time pressures
  • Interruptions
  • Computer system factors
  • Transfer of care
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6
Q

How can SOPs reduce the risk of prescribing errors?

A
  • can reduce the risk by outlining processes for clinically checking and accuracy checking
  • more than one person checking
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7
Q

What is important when storing medicines to reduce the risk of error?

A
  • Proper storage is essential, including addressing look-alike, sound-alike drugs to prevent mix-ups.
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8
Q

What role does reporting play in reducing prescribing errors?

A
  • Reporting errors through an error log and investigating contextual factors (environment, personal, organizational) helps identify issues and improve future practice
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9
Q

What type of culture is important to reduce errors in pharmacy?

A
  • culture based on fairness, quality, safety, transparency, learning, and reporting leads to better care and fewer errors
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10
Q

What are the key principles (RPS) regarding patient safety?

A
  • Patient safety is paramount.
  • Deliberate harm and unacceptable risk impacting patient safety must not be tolerated.
  • Patient safety is maintained by healthcare professionals being candid, raising concerns, and learning from incidents.
  • Individual accountability must be fair and proportionate, considering root causes, system deficiencies, and contributing factors.
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11
Q

How is safety improved after an error in pharmacy practice ?

A
  • Safety is improved by reporting and learning from errors, which helps prevent similar issues in the future
  • only happens when individuals feel safe to report
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12
Q

What are the RPS error reporting guidlines ?

A
  • standard 1 = open and honest
  • standard 2 = should report
  • standard 3 = learn
  • standard 4 = share
  • standard 5 = act
  • standard 6 = review
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13
Q

What are the steps to handle a dispensing error?

A
  • Inform the patient promptly.
  • Make things right (this may involve contacting the prescriber).
  • Offer an apology.
  • Inform colleagues involved in the error.
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14
Q

What conditions must be met for a legal defence to be used in the case of a dispensing error?

A
  • Occurred in a registered pharmacy.
  • Was dispensed by or under the supervision of a registered pharmacist/technician.
  • Was supplied against a prescription, PGD, or direction from a prescriber.
  • Was promptly notified to the patient once the pharmacy team became aware of the error.
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15
Q

What does the GPhC do when a concern about fitness to practice is raised?

A
  • GPhC reviews reports and investigates them against a set of criteria to determine the next steps
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16
Q

What steps are involved in investigating a concern raised about fitness to practice?

A
  • Gathering facts (e.g., speaking to the person raising the concern, speaking to the professional, conducting site visits, etc.).
  • Reviewing the investigation against threshold criteria.
  • Deciding whether to refer the case to the Investigating Committee or the Fitness to Practice Committee (only in serious cases)
17
Q

What are the criteria for referring a case to the Investigating Committee according to the GPhC?

A
  • The conduct or performance presents a risk to patient or public safety.
  • The conduct undermines or is likely to undermine confidence in the pharmacy profession.
  • There has been a serious or persistent failure to meet the standards for pharmacy professionals.
  • The pharmacy professional’s honesty or integrity can no longer be relied upon.
  • Adverse health (physical or mental) presents a risk to the professional’s ability to practice safely or effectively.
  • It is in the public interest to refer.

Law And Ethics (11 decks)

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