Exam 1 - Basic Error Prevention, Errors of Omission, & REMS Programs Flashcards
What is the ISMP’s mediation error prevention toolbox?
ISMP published a toolkit to help provide guidance to pharmacists looking for ways to decrease their risk of medication errors
ISMP tips
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)
ISMP tips: Forcing functions and constraints example
Removing all KCl vials from all pt care areas
Using specially designed oral syringes that cannot be connected to parenteral lines
ISMP tips: Automation and computerization example
Computerized physician order entry (CPOE)
Drug info systems
Fail-safe design mechanisms on IV pumps
ISMP tips: Drug protocols and standard order forms example
Standardize safe order communication
ISMP tips: Independent double check systems and other redundancies example
Don’t check your own work
ISMP tips: Rules and policies example
These should be used to support more effective error prevention strategies rather than to control people’s actions
ISMP tips: Education and information examples
Important to reducing errors, but CANNOT be used alone
Basic error prevention strategies
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)
Aspects of minimizing clutter
Countertops
Work stations
Patient care areas
Electronic clutter
Countertops
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
Patient care areas
Should have minimal clutter
Vaccine/med admin areas should only have the necessary supplies and emergency med kit
Work stations
Should only have necessary tools to complete the processes needed
Example: verification station doesn’t need all sizes of vials readily available
Electronic clutter
EMRs are vast resources, but unnecessary info in pt notes/chart can make it hard to find required info
Keep it brief
Use barcodes
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!
Don’t do every step on your own
You aren’t working alone, rely on your people
Try not to check your own work when possible
What does “rely on your people” apply to?
Compounding products
Filling rxs
Batch prepping IVs
What does it mean to “try not to check your own work when possible?”
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
Involve the pt
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)
Why is it important for the pt to know what meds they take?
Involving the pt/caregiver in dispensing process (at pick up) can help reduce errors
Trust your gut
If something seems of, doesn’t make sense, or seems strange, ASK
Be proactive
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?
Track errors
Error reporting is an important part of error prevention
Go above reporting errors, ensure you follow up to see what happened
What can common prescription and transcribing errors relate to?
Errors of omission
Abbreviations
Stemming
Weight, volume, units
Decimals and spaces
Unreconciled meds
Hold orders
Legibility
Spoken or verbal orders
(SLASHED Up Women)
What are errors of omission?
Leaving out crucial info
Where can errors of omission be seen?
Prescribing
Transcribing
Med labels
Pt charts
Do abbreviations actually save time?
Potentially for the person writing the order
On the other hand, it can be misinterpreted or cause confusion
What is stemming?
Creating shortened versions of drug names that are easily misinterpreted
What abbreviations should NOT be used?
Abbreviations for drug names
Anything for the word daily
U
µg
sq or sc
A/ or &
cc
D/C
What should you use instead of µg?
Mcg
What should you use instead of sq or sc?
Subcut
What should you use instead of a/ or &?
The word and
What should you use instead of cc?
mL
What should you use instead of D/C?
Discontinue or discharge
Weight, volume, and units
Prescribers should use metric system
USP doesn’t recognize apothecary system
Apothecary vs metric: weight
Apothecary:
- dram (mistaken for tbsp)
- grain
Metric: gram
Apothecary vs metric: volume
Apothecary: minims
Metric: mL
Apothecary vs metric: units
Apothecary: one-half (ss)
Decimals and spaces
Major source of errors
Easily missed, especially on lined order sheets, carbon copies, or faxes
Avoid using decimal places when not mandatory
Examples of NOT using decimals when not mandatory
Use 500 mg instead of 0.5 g
Use 125 mcg instead of 0.125 mg
Leading zeros
ALWAYS use leading 0 for values less than 1
Ex. 0.1 not .1
Trailing zeros
NEVER use when not necessary
Ex. 10 not 10.0
In errors of omission, what vital information can prescribers leave off the order?
Route
Strength
Qty
Some orders are incomplete due to _____
Examples?
Vagueness
Ex. Continue all meds, resume all home meds
Unreconciled meds: institute for healthcare improvement
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
Unreconciled meds: JCAHO and NPSG
Requires hospitals to reconcile meds across the continuum of care
Med reconciliation is a NPSG for…
Hospitals
Ambulatory care
Assisted living
Behavioral health
Home care/long term care orgs
Hold orders
Errors are likely when orders are put on hold w/ no explicit directions for restarting
If they don’t have resume instructions, discontinue them
Why is it likely for med errors to happen when meds are put on hold w/ no explicit directions for restarting?
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
What can poorly written (legibility) orders lead to?
Delay of med admin
Delay of overall care
What issue happens when you have to clarify orders due to poor handwriting?
Workflow is interrupted, increasing the chance of errors
In 90,000 malpractice claims over a 7 year period, misinterpreted rxs ranked ___ in expense and prevalence
2nd
What is the goal of standardized order sets?
Avoid illegible handwriting
Reduce variation in how care is provided to pts
What are considerations w/ standardized order sets?
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
Why should verbal orders be avoided when possible?
Errors are likely
Person taking the order may assume whoever is calling it in heard the prescriber right and is pronouncing everything right
Fraudulent orders
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
Suggestions for reducing errors in verbal orders
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)
What are some issues w/ medication samples?
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
What is second victim syndrome (SVS)?
Phenomenon of a clinician becoming victimized by an unanticipated adverse medical event (pt is primary victim, clinician is secondary)
What are the 5 rights of second victims?
- Treatment that is just
- Respect
- Understanding and compassion
- Supportive care
- Transparency and the opportunity to contribute
What are the 3 stages of helping 2nd victims?
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
Emotional first aid
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
How do you engage in effective emotional first aid?
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
Support by trained peers
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
Support by mental health professionals
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
What are the stages of support by mental health professionals?
Drop out
Survive
Thrive
Drop out
Provider leaves current job, specialty, or clinical care altogether
Survive
Provider stays at current employment but is haunted by event and continues to have long lasting SVS symptoms
Thrive
Provider adopts a growth mindset and uses the experience to better the systems process to benefit future pts
What is REMS?
Drug safety program that the FDA can require for certain meds that have serious safety concerns
Helps ensure the benefit outweighs risk
What is REMS designed to do?
Reinforce med use behaviors/actions that support safe use of that med
Focuses on preventing, monitoring, or managing a specific serious risk
What is REMS NOT designed to do?
NOT designed to mitigate all potential adverse risks of med
What is the role of pts and caregivers in REMS?
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
What are the roles of HCPs and prescribers?
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
What is the role of pharmacies in REMS?
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
Some REMS require pharmacies to be certified to dispense that med. What does this usually involve?
Designating an authorized rep to:
- complete the training
- ensure compliance w/ policies/procedures
- ensure staff is trained appropriately
There are currently __ medications w/ actively approved REMS programs
65
Where can you find the list of meds w/ approved REMS?
Approved REMS on fda.gov
What does the REMS public dashboard provide?
Info on all past & currently active REMS programs
REMS materials, med guides (as applicable), history of the med
