Exam 1 - System Aspects That Contribute to Medication Errors

Question 1

What are the ISMP key elements of the medication use system?

Answer 1

Patient information

Drug information

Communication of drug info

Drug labeling, packaging, and nomenclature

Drug storage, stock, standardization, and distribution

Drug device acquisition, use, and monitoring

Environmental factors

Staff competency and education

Patient education

Quality processes and risk management

(Queen’s Pretty DDD Cups Don’t Even Seem Perky)

Question 2

Patient information: clinical

Answer 2

Allergies
Lab results
Diagnosis

Question 2

What falls under the category of “patient information?”

Answer 2

Demographic
Clinical
Administrative

Question 3

Patient information: administrative

Answer 3

Insurance

Question 4

Patient information: demographic

Answer 4

Age
Weight
Contact info
PMH

(Play With A Cat)

Question 5

Drug information should be readily accessible through a variety of sources. What are these sources?

What is the crucial aspect of this info?

Answer 5

Drug references
Protocols
Formularies
Guidelines

Crucial that the info is up to date

Question 6

What is “drug information?”

Answer 6

Accurate & relative drug info provided to all healthcare professionals involved in the medication use process

This can reduce the # of preventable ADEs

(Basically just standard info about drugs that’s available to you)

Question 7

What does miscommunication of orders lead to?

Answer 7

A variety of errors

(Communication of orders)

Question 8

What errors can miscommunication lead to? (Communication of orders)

Answer 8

Delay of treatment

Incorrect treatment, meds, diagnosis, or follow up care

Duplication of therapies

(DID)

Question 9

What does The Joint Commission (TJC) require of a verbal order? Why?

Answer 9

The person taking the oder should record (write) it and read (NOT repeat) it back to the prescriber

Ensures accuracy in hearing the order and in the transcription

Question 10

What falls under the category of “Drug labeling, packaging, and nomenclature?”

Answer 10

Tall man lettering
Abbreviations
LASA
Labeling

(TALL)

Question 11

What is the purpose of color coded labels?

Answer 11

It is a reasonable way of discouraging unintentional swaps of meds

ISMP receives reports of vial/syringe swaps due to look alike labels/caps

(Color coding isn’t perfect but if one label is orange and the other is purple, you’re probably not going to mix them up)

Question 12

What is the most common unintentional swap? (Color coded labels)

Answer 12

Intra-class medication swaps

Question 13

What is the disadvantage of relying solely on color coded labels?

Answer 13

Color blindness
Incorrect interpretations

(Think about the IV bags marked w/ yellow and orange and how easy that would be to mix up)

Question 14

Standardize 4 safety (standardization, storage, distribution)

Answer 14

ASHP developed the first national, interprofessional effort to standardize med concentrations to help reduce errors — particularly during transitions of care

Created 4 standard lists to help guide safety-centered care

Question 15

What standard lists were created to help guide safety-centered care?

Answer 15

1. Adult Continuous Infusion Standards
2. Compounded Oral Liquid Standards
3. Pediatric Continuous Infusion Standards
4. PCA and epidural standards

(CAPP)

Question 16

What can pharmacists play a role in the standardization of?

Answer 16

Administration times
Drug concentrations
Dose concentrations stocked

Question 17

Standardization, storage, and distribution pyramid from top to bottom

Answer 17

Operational considerations (cost and waste)

Use more concentrated when possible

Limit to one concentration when possible

FDA approved commercial products

Patient clinical needs

Question 18

What falls under the category “environmental factors?”

Answer 18

Poor lighting
Interruptions
Noise
Significant workload

(PINS)

Question 19

What falls under the category “staff competency and education?”

Answer 19

New medications being used or stocked

High alert medications

Medication errors that have occurred both internally and externally

Protocol changes and updates

Policies and procedures related to medication use

Question 20

Patient education

Answer 20

Patients play a vital role in preventing medication errors

**Encourage patients to ask questions and seek answers about their meds (this is bolded in slides)

ALWAYS advocate for your patients

Teach them to advocate for themselves

Question 21

What falls under the category “quality and risk management?”

Answer 21

Strategies used to reduce errors

Methods that promote the detection AND correction of errors BEFORE they reach the patient

Focus on the process and system, not the individual

(Stupid Mother Fucker)

Question 22

Who created the Medication Error Index?

Answer 22

National Coordinating Council for Medication Error Reporting and Prevention

Question 23

What does the Medication Error Index do?

Answer 23

Classifies medication errors based on severity of the outcome to the patient

Question 24

The Medication Error Index was created with the idea of…

Answer 24

Having a consistent and systematic method for tracking errors across institutions

ISMP MERP (medication error reporting system) uses this index

Question 25

What are contributing factors in the Medication Error Index?

Answer 25

1. Error reached the patient
2. If the patient was harmed, to what degree?

Question 26

NCC MERP Index: Category A

Answer 26

Events that have the capacity to cause error

Question 27

NCC MERP Index: Category B

Answer 27

Error occurred, but did NOT reach the patient

(Errors of omission DO reach the pt)

Question 28

NCC MERP Index: Category C

Answer 28

Error occurred, DID reach the patient, but did NOT cause harm

Question 29

NCC MERP Index: Category D

Answer 29

Error occurred and DID reach the patient

Patient required monitoring to confirm no harm or the patient required intervention to preclude harm

Question 30

NCC MERP Index: Category E

Answer 30

Error occurred that could have contributed to or resulted in temporary harm and required intervention

Question 31

NCC MERP Index: Category F

Answer 31

Error occurred that could have contributed to or resulted in temporary harm and required initial or prolonged hospitalization

Question 32

NCC MERP Index: Category G

Answer 32

Error occurred that may have contributed to or caused PERMANENT patient harm

Question 33

NCC MERP Index: Category H

Answer 33

Error occurred that needed intervention to sustain life of patient

Question 34

NCC MERP Index: Category I

Answer 34

Error occurred that could have contributed to or resulted in a patient’s death

Question 35

Who produces a list of National Patient Safety Goals (NPSG) annually?

Answer 35

The Joint Commission

Question 36

The NPSG has different focus points for various healthcare settings. What are these settings?

Answer 36

• Ambulatory health
• Assisted living community
• Behavioral healthcare & human services
• Critical access hospital
• Home care
• Hospital
• Laboratory
• Nursing care center
• Office based surgery

(Never Let A Bitch Ass Hoe Have Old Cooch)

Question 37

What was the last NPSG for 2024?

Answer 37

Prevent mistakes in surgery

Correct surgery on the correct patient on the correct part of the body

Use time out method to ensure mistake is not being made