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Patient Safety > Exam 1 - Basic Error Prevention, Errors of Omission, & REMS Programs > Flashcards

Exam 1 - Basic Error Prevention, Errors of Omission, & REMS Programs Flashcards

1
Q

What is the ISMP’s mediation error prevention toolbox?

A

ISMP published a toolkit to help provide guidance to pharmacists looking for ways to decrease their risk of medication errors

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2
Q

ISMP tips

A

Forcing functions and constraints

Automation and computerization

Drug protocols and standard order forms

Independent double check systems and other redundancies

Rules and policies

Education and info

(A Damn FIRE)

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3
Q

ISMP tips: Forcing functions and constraints example

A

Removing all KCl vials from all pt care areas

Using specially designed oral syringes that cannot be connected to parenteral lines

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4
Q

ISMP tips: Automation and computerization example

A

Computerized physician order entry (CPOE)

Drug info systems

Fail-safe design mechanisms on IV pumps

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5
Q

ISMP tips: Drug protocols and standard order forms example

A

Standardize safe order communication

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6
Q

ISMP tips: Independent double check systems and other redundancies example

A

Don’t check your own work

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7
Q

ISMP tips: Rules and policies example

A

These should be used to support more effective error prevention strategies rather than to control people’s actions

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8
Q

ISMP tips: Education and information examples

A

Important to reducing errors, but CANNOT be used alone

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9
Q

Basic error prevention strategies

A

Minimize clutter
Use barcodes
Don’t do every step on your own
Involve the pt
Trust your gut
Be proactive
Track errors

(MUD TIT Bitch)

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10
Q

Aspects of minimizing clutter

A

Countertops
Work stations
Patient care areas
Electronic clutter

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11
Q

Countertops

A

Clean off counter of any unnecessary:
- paperwork
- notes
- supplies
- etc

Do this at the end of the day to make sure you start your morning clutter free

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12
Q

Patient care areas

A

Should have minimal clutter

Vaccine/med admin areas should only have the necessary supplies and emergency med kit

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13
Q

Work stations

A

Should only have necessary tools to complete the processes needed

Example: verification station doesn’t need all sizes of vials readily available

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14
Q

Electronic clutter

A

EMRs are vast resources, but unnecessary info in pt notes/chart can make it hard to find required info

Keep it brief

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15
Q

Use barcodes

A

Do NOT use workarounds
- scan every vial
- do not keep lists of barcodes for common meds (scan actual vial)
- do not scan the barcodes out for multiple pts then go back and fill all the rxs

Pts and meds have barcodes — use them!

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16
Q

Don’t do every step on your own

A

You aren’t working alone, rely on your people

Try not to check your own work when possible

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17
Q

What does “rely on your people” apply to?

A

Compounding products
Filling rxs
Batch prepping IVs

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18
Q

What does it mean to “try not to check your own work when possible?”

A

If you’re working w/ another pharmacist, have them check the work that you did (and check theirs for them)

Not always possible but the best option

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19
Q

Involve the pt

A

Does the pt know what meds they take?

Does the pt know what medical conditions they have? (Is the med list missing meds or have extra meds based on the indications the pt tells you)

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20
Q

Why is it important for the pt to know what meds they take?

A

Involving the pt/caregiver in dispensing process (at pick up) can help reduce errors

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21
Q

Trust your gut

A

If something seems of, doesn’t make sense, or seems strange, ASK

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22
Q

Be proactive

A

Stay on top of tasks

Don’t be afraid to be the 1st at completing a task or asking questions

Can you work ahead and NOT effect the quality of pt care?

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23
Q

Track errors

A

Error reporting is an important part of error prevention

Go above reporting errors, ensure you follow up to see what happened

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24
Q

What can common prescription and transcribing errors relate to?

A

Errors of omission
Abbreviations
Stemming
Weight, volume, units
Decimals and spaces
Unreconciled meds
Hold orders
Legibility
Spoken or verbal orders

(SLASHED Up Women)

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25
Q

What are errors of omission?

A

Leaving out crucial info

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26
Q

Where can errors of omission be seen?

A

Prescribing
Transcribing
Med labels
Pt charts

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27
Q

Do abbreviations actually save time?

A

Potentially for the person writing the order

On the other hand, it can be misinterpreted or cause confusion

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28
Q

What is stemming?

A

Creating shortened versions of drug names that are easily misinterpreted

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29
Q

What abbreviations should NOT be used?

A

Abbreviations for drug names
Anything for the word daily
U
µg
sq or sc
A/ or &
cc
D/C

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30
Q

What should you use instead of µg?

A

Mcg

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31
Q

What should you use instead of sq or sc?

A

Subcut

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32
Q

What should you use instead of a/ or &?

A

The word and

33
Q

What should you use instead of cc?

A

mL

34
Q

What should you use instead of D/C?

A

Discontinue or discharge

35
Q

Weight, volume, and units

A

Prescribers should use metric system

USP doesn’t recognize apothecary system

36
Q

Apothecary vs metric: weight

A

Apothecary:
- dram (mistaken for tbsp)
- grain

Metric: gram

37
Q

Apothecary vs metric: volume

A

Apothecary: minims
Metric: mL

38
Q

Apothecary vs metric: units

A

Apothecary: one-half (ss)

39
Q

Decimals and spaces

A

Major source of errors

Easily missed, especially on lined order sheets, carbon copies, or faxes

Avoid using decimal places when not mandatory

40
Q

Examples of NOT using decimals when not mandatory

A

Use 500 mg instead of 0.5 g
Use 125 mcg instead of 0.125 mg

41
Q

Leading zeros

A

ALWAYS use leading 0 for values less than 1

Ex. 0.1 not .1

42
Q

Trailing zeros

A

NEVER use when not necessary

Ex. 10 not 10.0

43
Q

In errors of omission, what vital information can prescribers leave off the order?

A

Route
Strength
Qty

44
Q

Some orders are incomplete due to _____

Examples?

A

Vagueness

Ex. Continue all meds, resume all home meds

45
Q

Unreconciled meds: institute for healthcare improvement

A

Poor communication of medical info at transaction points is responsible for up to 50% of all med errors and up to 20% of ADEs in hospitals

46
Q

Unreconciled meds: JCAHO and NPSG

A

Requires hospitals to reconcile meds across the continuum of care

47
Q

Med reconciliation is a NPSG for…

A

Hospitals
Ambulatory care
Assisted living
Behavioral health
Home care/long term care orgs

48
Q

Hold orders

A

Errors are likely when orders are put on hold w/ no explicit directions for restarting

If they don’t have resume instructions, discontinue them

49
Q

Why is it likely for med errors to happen when meds are put on hold w/ no explicit directions for restarting?

A

May inadvertently not be resumed

May be resumed too soon

Easily forgotten about and not restarted when appropriate

Some systems can generate daily summary of current prescribed therapies and recently discontinued meds

50
Q

What can poorly written (legibility) orders lead to?

A

Delay of med admin
Delay of overall care

51
Q

What issue happens when you have to clarify orders due to poor handwriting?

A

Workflow is interrupted, increasing the chance of errors

52
Q

In 90,000 malpractice claims over a 7 year period, misinterpreted rxs ranked ___ in expense and prevalence

A

2nd

53
Q

What is the goal of standardized order sets?

A

Avoid illegible handwriting

Reduce variation in how care is provided to pts

54
Q

What are considerations w/ standardized order sets?

A

Should be based on institution/dept (NOT individual prescribers)

Printed forms providing a list of meds to choose from should be avoided (easy to circle the wrong one)

Often include meds that cover all possible scenarios and every pt may not need every med option

55
Q

Why should verbal orders be avoided when possible?

A

Errors are likely

Person taking the order may assume whoever is calling it in heard the prescriber right and is pronouncing everything right

56
Q

Fraudulent orders

A

Lay person may attempt to call in rx for med (often controlled)

Be suspicious when an unknown prescriber calls in an rx:
- get call back #
- verify # or call to verify rx if there is concern

57
Q

Suggestions for reducing errors in verbal orders

A

Limit spoken orders to those for true emergencies

Always read back order

Confirm dose by expressing # as single digits

Prohibit certain high alert meds from being verbal orders

Have 2nd person listen when possible

Require mg/kg for all neonatal/peds scrips

Both prescriber & receiver should spell unfamiliar drug names w “t as in tom”

Immediately transcribe spoken orders to rx or chart (scrap paper creates opportunity for error)

58
Q

What are some issues w/ medication samples?

A

Usually dispensed prior to computerized safety checks such as drug interactions, duplicate therapies, allergies, contraindications

Often dispensed by physicians without an independent double check by another HCP

Pt might not get written instructions or instructions might not be near the med

Packaging can be confusing

Can be overlooked in recalls/exp date checks

Unsecured storage allows unauthorized access

59
Q

What is second victim syndrome (SVS)?

A

Phenomenon of a clinician becoming victimized by an unanticipated adverse medical event (pt is primary victim, clinician is secondary)

60
Q

What are the 5 rights of second victims?

A
  • Treatment that is just
  • Respect
  • Understanding and compassion
  • Supportive care
  • Transparency and the opportunity to contribute
61
Q

What are the 3 stages of helping 2nd victims?

A

Stage 1: emotional first aid provided by a trusted colleague or mentor

Stage 2: support by trained peers

Stage 3: support by mental health professionals

62
Q

Emotional first aid

A

Post-incident immediate discussion to allow the involved to debrief in time following incident before returning to work

Trusted colleague/mentor should strive to normalize the providers feelings by recognizing that all providers are human

63
Q

How do you engage in effective emotional first aid?

A

Be in a private place away from the clinical event as soon as safely possible

Use open ended questions like “how are you feeling” or “do you want to talk about it”

Listen and allow them to control the conversation

Give the provider time alone to collect their thoughts before returning to clinical duties — some providers may need to leave the worksite

64
Q

Support by trained peers

A

Administered by specific coworkers who are trained in mentoring and supporting peers after an adverse/traumatic event

Trained peer will follow up in the days and weeks following the incident to ensure providers wellbeing and referral for other support as needed

65
Q

Support by mental health professionals

A

Should be available to ALL clinical employees and is encouraged if the providers 2nd victim symptoms interfere w/ professional/personal lives, or if symptoms fail to improve/worsen over time

66
Q

What are the stages of support by mental health professionals?

A

Drop out
Survive
Thrive

67
Q

Drop out

A

Provider leaves current job, specialty, or clinical care altogether

68
Q

Survive

A

Provider stays at current employment but is haunted by event and continues to have long lasting SVS symptoms

69
Q

Thrive

A

Provider adopts a growth mindset and uses the experience to better the systems process to benefit future pts

70
Q

What is REMS?

A

Drug safety program that the FDA can require for certain meds that have serious safety concerns

Helps ensure the benefit outweighs risk

71
Q

What is REMS designed to do?

A

Reinforce med use behaviors/actions that support safe use of that med

Focuses on preventing, monitoring, or managing a specific serious risk

72
Q

What is REMS NOT designed to do?

A

NOT designed to mitigate all potential adverse risks of med

73
Q

What is the role of pts and caregivers in REMS?

A

Can vary depending on REM type

Pt can get specific counseling about risk, actions to mitigate risk, symptoms to watch for

Some REMS have pt sign form saying they understand the risks — some make them to lab testing

REMS provide access to meds w/ serious risk that would not otherwise be available

74
Q

What are the roles of HCPs and prescribers?

A

Prescriber requirements vary

Mostly, prescribers get info from mfrs about REMS

Some programs require prescribers to enroll in programs, train, and document pt counseling, enrollment, overall compliance

75
Q

What is the role of pharmacies in REMS?

A

Some get REMS communications from mfrs

Some REMS require pharmacy to be certified to dispense that med

Individual pharmacists may be needed to complete training, verify safe use conditions, or provide counseling/education to pts

76
Q

Some REMS require pharmacies to be certified to dispense that med. What does this usually involve?

A

Designating an authorized rep to:
- complete the training
- ensure compliance w/ policies/procedures
- ensure staff is trained appropriately

77
Q

There are currently __ medications w/ actively approved REMS programs

A

65

78
Q

Where can you find the list of meds w/ approved REMS?

A

Approved REMS on fda.gov

79
Q

What does the REMS public dashboard provide?

A

Info on all past & currently active REMS programs

REMS materials, med guides (as applicable), history of the med

Patient Safety (11 decks)

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