Exam 1

Question 1

Identify technology that can be used to mitigate medication errors

Answer 1

Computerized physician order entry (CPOE)
Clinical decision support (CDS)
Bar coding
Automated dispensing device (ADD)
Smart intravenous infusion pumps

Question 2

Describe the medication use process

Answer 2

order the drug, transcribe the drug (read and interpret drug correctly), dispense the drug, administer the drug

Question 3

Describe the role of various systems and factors in creating safety and in causing errors during the prescribing process

Answer 3

prescribing decision: prescriber factors, patient factors, medication factors, patient preferences, organizational factors

causes of prescribing errors: individual factors, team factors, work environment factors, patient factors, latent conditions

Question 4

Identify aspects of the medication use and dispensing processes as they pertain to medication errors

Answer 4

dispensing process: receipt of Rx, legal check of Rx, clinical check of Rx, label generation, stock selection, medication assembly, product labeling, final accuracy check, patient counseling

medication use: ensure patient is receiving right dosage and instructions on how to use it, make sure patient is using medication correctly and taking it at the right times

Question 5

Differentiate between a medication error and a near miss

Answer 5

a medication error is an error that reaches the patient and does direct harm
a near miss is an error that does not reach the patient but occurred in the medication process

Question 6

List the types of potential medication errors associated with administration

Answer 6

wrong dose, choice, time, frequency, drug, time, technique, route
known allergy
preparation error
missed dose/omission
extra dose
inadequate monitoring

Question 7

Describe the steps in the administration process that are intended to prevent medication errors and adverse drug
events

Answer 7

right patient (2 identifiers)
right med
right dose
right route
right time
right documentation

Question 8

Identify the purpose of medication reconciliation

Answer 8

Process of identifying and maintaining the most accurate list of all medications a patient is taking
Using this list to provide correct
medications for the patient anywhere
within the healthcare system
Especially at transfer of care

Question 9

Understand the concepts of Adverse Drug Reaction

Answer 9

type A –> predictable, common and less serious, well documented before licensing
type B –> rare, unexpected, potentially serious or fatal, usually not dose dependent, not usually documented before licensing

Question 10

Identify the risk factors (vulnerable populations) of ADR

Answer 10

elderly patients
neonates and children
ethnic variations
genetic variations
renal dysfunction
liver disease
gender
multiple drug use
allergies
inappropriate administration
pregnancy
breastfeeding

Question 11

Reporting ADR/Management ADR/Drugs that most frequently caused ADRs

Answer 11

The FDA Adverse Event Reporting System (FAERS) is a database that collects
information on adverse event and medication error reports submitted to FDA.

MedWatch is the Food and Drug Administration’s (FDA) program for reporting
serious reactions, product quality problems, therapeutic inequivalence/failure, and product use errors with human medical products,
including drugs, biologic products, medical devices, dietary supplements, infant formula, and cosmetics

Questions to ask to identify an ADR
* Have any new drugs been started?
* How soon after starting the new drug did the reaction occur?
* Could the reaction be due to the medical condition or to
another disease?
* May the ADR have been precipitated by a patient factor?
* Could it have been precipitated by a drug interaction?
* Did the reaction stop when the drug was stopped?
* Did the reaction re-occur when the drug was restarted?
* Is it the drug, or an excipient that has caused the ADR?
* Is it an allergic reaction?

antidepressants and opioids most commonly cause ADRS

Question 12

Drug interaction/examples

Answer 12

Pharmacodynamic: Interactions occur when a medicine modifies the effect of another medicine but without altering the blood
level of that medicine
* Coadministration of a beta-blocker with a beta-agonist may give rise to bronchospasm and limiting
the effect of beta agonist
* Combination of ACE inhibitor and Potassium sparing diuretic both increase potassium levels and can cause fatal hyperkalemia
Pharmacokinetic
* Interaction at site of absorption
* Distribution interactions
* Metabolism interactions
* Excretion interactions

Question 13

Identify the purpose of reporting medication incidents

Answer 13

Medication error is seldom attributed to any
one individual or factor:
▪ Poor teamwork and communication
▪ Insufficient or missing information
▪ Illegibility
▪ Inadequate training
▪ Excessive workload
▪ Staff shortages
▪ Interruptions and distractions
Need to report to facilitate identifying
system problems and correcting them to
prevent future errors

Question 14

Identify medication events that should be reported

Answer 14

Any unintended or unexpected incident,
which could have or did lead to harm for one
or more patients
Adverse drug event
Adverse drug reaction
Medication Reaction
Near Miss

Question 15

Identify who reports should be sent to

Answer 15

Product manufacturer
Equipment and technology vendor
The Joint Commission – Sentinel Events
Food and Drug Administration (FDA)
o FDAs Adverse Event Reporting System (AERS); part of FDAs MedWatch program
Institute for Safe medication Practices (ISMP)
Medication Error Reporting Program (MERP)
Patient Safety Organizations (PSOs)

Question 16

Describe deterrents to reporting medication incidents

Answer 16

Hierarchical hospital culture/structure where
nursing staff disagreed about the definition of
reportable errors
Fear of response of administrators and peers
to a reported error
Amount of time and effort involved in
documenting and reporting an error

Question 17

Describe strategies to encourage reporting of medication incidents

Answer 17

Agreement on the definition of an error
Supporting and simplifying error reporting
Institutionalizing a culture of justice
Learning is encouraged and blaming is discouraged
Capitalizing on reports to determine system
factors contributing to error
Positive incentives for medication
administration error (MAE) reporting
Anonymous “hot line”

Question 18

Identify common communication strategies in the healthcare system and their potential influence on medical error propagation

Answer 18

emailing colleagues, phone and fax are primary means –> miscommunication makes up 80% of reasons for error so make sure to communicate appropriately in these ways

Question 19

Review supported tools and behaviors to improve teamwork and communication

Answer 19

shared mental models, mutual respect, trust, close-loop communication

Question 20

Apply effective communication strategies to mitigate medical related errors

Answer 20

1. concrete –> clear picture of what’s being said, data backs this up
2. coherent –> logical and understood
3. clarity –> goals/purpose stated
4. commitment –> measures dedication to argument, delivered well –> increases morale
5. consistency –> choice of words matter, utilize least possible words, no repetition
6. completeness –> each message must have logical conclusion
7. courteous –> relay that you’re honest, respectful, open, and polite

Question 21

Define patient safety and describe “acceptable minimum”

Answer 21

current knowledge, resources available, context in which care is delivered vs. risk of non-treatment or other treatment

Question 22

Compare and contrast iatrogenic adverse events, patient safety incidents, and critical incidents

Answer 22

iatrogenic adverse events –> occur as a result of medical management and result in measurable disability, negligent adverse events are those events caused by a failure to meet standards of care reasonably expected of the average healthcare professional

patient safety incidents –> an unintended/unexpected incident that could’ve or did harm a patient, includes near misses

critical incidents –> incidents that are uniquely pivotal: desirable or undesirable, significant for potential/actual harm, event may reveal important hazards

Question 23

Describe the Swiss Cheese Model in relation to healthcare

Answer 23

healthcare systems have lots of preventative measures in place to prevent medical errors and near misses, but when there are “holes” in these measures a problem can bypass them when aligned perfectly and cause harm

Question 24

Describe the complexities of healthcare systems and how this can affect patient safety

Answer 24

multiple-complex components
interacting with one another to
achieve a measurable outcome

routine tasks connect multiple
people, activities, and
technologies

social factors –> psychological, team dynamics & communication, managerial
technical factors –> equipment, information technology support/access, infrastructure

safety improvement efforts needed to be targeted at this components

Question 25

Describe system reliability and how this can affect patient safety

Answer 25

ability of a system to routinely perform its function without failure
prevent failure, identify and mitigate failure, redesign process based on the critical failures

managing:
human factors design to reduce rate of error
barriers to prevent failure
recovery to capture failures before they become critical
redundancy to limit effects of failure

Question 26

Describe the influence of a just culture on patient safety

Answer 26

identifying events as opportunities to
improve our understanding of risk

Five components of mindfulness:
1. A constant concern about the
possibility of failure
2. Yielding to expertise regardless of
rank or status
3. Ability to adapt when the
unexpected occurs
4. Ability to concentrate on a task
while having a sense of the big
picture
5. Ability to alter and flatten the
hierarchy to fit a specific situation

Question 27

Describe the relationship between safety and quality in healthcare

Answer 27

both safety and quality are needed to provide an efficient and working system that benefits patients and reduces chances of error

Question 28

Define Human Factors

Answer 28

study of human factors –> examines the relationship between people and systems, places emphasis on centering environment around clinician

Question 29

Describe the structure of SEIPS

Answer 29

people –> we are at the center of any system: we exist to perform, work, design, operate, avoid errors, etc.
tasks –> define what we need to achieve a goal: hierarchal task analysis, direct observation, examine differences
technology and tools –> assists people at the center of the system in performing tasks that will help people reach their goals
environment –> effect of the working environment and performance
organization –> must support all aspects of work environment (safety culture, preventing drift, balance between input, cost, quality)

Question 30

Understand Teamwork and Communication

Answer 30

lots of errors occur when the two break down

communication approaches: information engineering and social construction

teamwork includes: two or more people, team makes decisions, part of a larger system
effective teamwork includes: organizational structure, individual contribution, team process

improvements for both: briefings, debriefings, SBAR

Question 31

Describe duty-based ethics

Answer 31

people believe that all humans have some duties to other human beings and thus we must treat people as an end, never a means to an end

Question 32

Describe in detail the advantages and disadvantages of the duty-based framework

Answer 32

advantages: creates a system of rules with consistent expectations, “even-handedness” encourages treating everyone equally, focuses on following moral rules regardless of outcome, works best in situations where there is sense of obligation

disadvantages: can seem cold and impersonal, doesn’t guide us to determine which duty to follow when there are multiple, can be rigid in applying notion of duty to everyone regardless of personal info

Question 33

Describe and define the (4) ethical principles in ethics (autonomy, justice, beneficence, non-malfeasance)

Answer 33

autonomy –> patient has right to determine own care
justice –> equitable treatment for all
beneficence –> do good for patient
non-malfeasance –> do no harm (hippocratic oath)

Question 34

Identify the major safety issues related to technology in healthcare, surgery, diagnosis, and mental health

Answer 34

technology can be needed but unavailable for use, malfunction during use, used in ways other than intended, interact with other technology in unintended ways

Question 35

Describe the benefits of information technology in healthcare and possible uses of the technology

Answer 35

technology has great potential to improve safety, quality, and efficiency of care
technology can be used to prevent errors associated with bad writing, poor communication, provide easier access to patients at home, and create warnings systems/checks and balances

Question 36

Describe the process an organization should utilize for designing and implementing new technology

Answer 36

user’s of new technology should be properly trained
systems should fit in pre-established work practice
extensive consultation with potential users
must follow national guidelines, global initiatives, etc.

Question 37

Describe measures that should be implemented to prevent surgical errors

Answer 37

one person in charge of counting materials before and after surgery to ensure nothing is left inside in patient (checklists)
mark correct area before surgery to prevent wrong site surgery
use two patient identifiers and “time-out” procedure before invasive procedures
pre-operative patient/surgery/site verification process

Question 38

Describe the diagnostic process utilizing the system l and system ll approach

Answer 38

system I –> physician recognizes pattern and can help solve problem through intuition and their known knowledge
system II –> physician does not recognize pattern immediately and much more analytical reasoning needed

Question 39

What is Root Cause Analysis (RCA)?

Answer 39

identifying the underlying (root) causes of a problem
method of incident investigation
a diagnostic tool rather than a safety solution

Question 40

Describe the elements of RCA Process

Answer 40

1. gathering and mapping the info –> understand exactly what happened leading up and do investigative interviewing
2. identifying care and service delivery problems –> identify things that happened that shouldn’t have and vice versa
3. analyzing problems –> use fishbone diagram, analyze course of action
4. generating recommendations and solutions –> training in improvement science will assist with more effective selection and implementation of solutions
5. implement solutions –> monitor efficiency
6. writing the investigation report –> use RCA investigation report template

Question 41

Identify the components for effective RCA
investigation

Answer 41

1. avoid extremes of delayed problem diagnosis/wasting resources (correctly identify triggers)
2. obtain good-quality, accurate picture of problem
3. findings are robustly interpreted and credible conclusion drawn
4. ensure improvement is achieved, effective treatment and remedial action required
5. must have organization-wide support for RCA process

Question 42

Describe three RCA related theories

Answer 42

1. Swiss cheese model –> barriers designed to prevent errors are not perfect, when holes align problems occur
2. Incident decision tree –> provides guidance whether/when issues should be referred if concern of capability, recklessness, or maliciousness arise
3. Fishbone diagram –> identify the areas of where the root causes originated and how that led to the overall problem

Question 43

Definition of Safety Culture

Answer 43

the way that patient safety is thought about and implemented within an organization
how safety is perceived, valued, and prioritized

Question 44

Identify main components of safety culture

Answer 44

good leadership and teamwork
staff training
rule and safety processes
monitoring systems that identify and learn from incidents and communications
sharing to promote ongoing learning

Question 45

Identify tools to measure safety culture

Answer 45

Safety Attitude Questionnaire
Patient Safety Culture in Healthcare Organizations
Hospital Survey on Patient Safety Culture
Safety Climate Survey
Manchester Patient Safety Framework

Question 46

Describe the strategies to improve safety
culture

Answer 46

leaders prioritize safety in policy and practice
visible participation by leaders
standardized system-wide approach
holding managers/staff accountable
include safety in annual performance reviews
minimize sources of error
share info about success and improvement
list safety incidents and successes on notice boards

Question 47

What is the learning healthcare system

Answer 47

a system in which:
knowledge generation is so embedded into the core of the practice of medicine
it’s a natural outgrowth and product of the healthcare delivery process and leads to continual improvement in care

Question 48

Describe seven fundamental obligations

Answer 48

1. respect patients –> informed consent, protect their confidentiality of health info, respect autonomy
2. respect clinician judgment –> clinician has background and experience and thus their judgment is important to include in what is best course of action for patient
3. provide optimal care to each patient –> moral responsibilities to advance welfare of patient, risks are morally justified if outweighed by benefits
4. avoid imposing nonclinical risks –> avoid inflicting other kinds of harm (financially, socially, employment, etc.)
5. address unjust inequalities –> bar against learning activities that harm less fortunate patients and those that benefit well off patients, equality no matter patient’s background
6. conduct continuous learning activities –> contribute/conduct activities that advance healthcare quality and economic viability, improve services and system
7. patients to contribute to improving quality –> system positioned to provide each person with quality healthcare at a cost compatible with individual and economic well-being