Exam 1 - System Aspects That Contribute to Medication Errors Flashcards
What are the ISMP key elements of the medication use system?
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)
Patient information: clinical
Allergies
Lab results
Diagnosis
What falls under the category of “patient information?”
Demographic
Clinical
Administrative
Patient information: administrative
Insurance
Patient information: demographic
Age
Weight
Contact info
PMH
(Play With A Cat)
Drug information should be readily accessible through a variety of sources. What are these sources?
What is the crucial aspect of this info?
Drug references
Protocols
Formularies
Guidelines
Crucial that the info is up to date
What is “drug information?”
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)
What does miscommunication of orders lead to?
A variety of errors
(Communication of orders)
What errors can miscommunication lead to? (Communication of orders)
Delay of treatment
Incorrect treatment, meds, diagnosis, or follow up care
Duplication of therapies
(DID)
What does The Joint Commission (TJC) require of a verbal order? Why?
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
What falls under the category of “Drug labeling, packaging, and nomenclature?”
Tall man lettering
Abbreviations
LASA
Labeling
(TALL)
What is the purpose of color coded labels?
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)
What is the most common unintentional swap? (Color coded labels)
Intra-class medication swaps
What is the disadvantage of relying solely on color coded labels?
Color blindness
Incorrect interpretations
(Think about the IV bags marked w/ yellow and orange and how easy that would be to mix up)
Standardize 4 safety (standardization, storage, distribution)
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
What standard lists were created to help guide safety-centered care?
- Adult Continuous Infusion Standards
- Compounded Oral Liquid Standards
- Pediatric Continuous Infusion Standards
- PCA and epidural standards
(CAPP)
What can pharmacists play a role in the standardization of?
Administration times
Drug concentrations
Dose concentrations stocked
Standardization, storage, and distribution pyramid from top to bottom
Operational considerations (cost and waste)
Use more concentrated when possible
Limit to one concentration when possible
FDA approved commercial products
Patient clinical needs
What falls under the category “environmental factors?”
Poor lighting
Interruptions
Noise
Significant workload
(PINS)
What falls under the category “staff competency and education?”
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
Patient education
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
What falls under the category “quality and risk management?”
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)
Who created the Medication Error Index?
National Coordinating Council for Medication Error Reporting and Prevention
What does the Medication Error Index do?
Classifies medication errors based on severity of the outcome to the patient
The Medication Error Index was created with the idea of…
Having a consistent and systematic method for tracking errors across institutions
ISMP MERP (medication error reporting system) uses this index
What are contributing factors in the Medication Error Index?
- Error reached the patient
- If the patient was harmed, to what degree?
NCC MERP Index: Category A
Events that have the capacity to cause error
NCC MERP Index: Category B
Error occurred, but did NOT reach the patient
(Errors of omission DO reach the pt)
NCC MERP Index: Category C
Error occurred, DID reach the patient, but did NOT cause harm
NCC MERP Index: Category D
Error occurred and DID reach the patient
Patient required monitoring to confirm no harm or the patient required intervention to preclude harm
NCC MERP Index: Category E
Error occurred that could have contributed to or resulted in temporary harm and required intervention
NCC MERP Index: Category F
Error occurred that could have contributed to or resulted in temporary harm and required initial or prolonged hospitalization
NCC MERP Index: Category G
Error occurred that may have contributed to or caused PERMANENT patient harm
NCC MERP Index: Category H
Error occurred that needed intervention to sustain life of patient
NCC MERP Index: Category I
Error occurred that could have contributed to or resulted in a patient’s death
Who produces a list of National Patient Safety Goals (NPSG) annually?
The Joint Commission
The NPSG has different focus points for various healthcare settings. What are these settings?
- 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)
What was the last NPSG for 2024?
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
