Introduction to Medication Error & Safety

Question 1

Definition of ‘medication error’

Answer 1

A preventable event
that may cause or lead to inappropriate medication use or use or patient harm
while the medication is in control of health professional, patient or consumer

Question 2

Some issues involving medicines (3):

Answer 2

• Adverse drug events
• Adherence problems
• Medication errors

Question 3

Medication process

Answer 3

Prescribing-> Dispensing-> Administering-> Monitoring-> seeking help

Question 4

Strategies to prevent errors (5):

Answer 4

1) computerised physician ordering entry systems- w. clinical decision support system
2) Utilising clinical pharmacist
3) Double-checking medication orders
4) Incident reporting
5) Education & Training

Question 5

• '’Systems approach’’ towards errors rather than ‘‘persons approach’’ because…. (2)
• Focus on systems of work

Answer 5

Humans view as fallible

Errors are inevitable

Question 6

Aims of systems approach of error reporting (3)

Answer 6

• Learn from errors and near misses
• Establish nationwide solutions
• Prevent further errors

Question 7

Error reporting important because without it (3):

Answer 7

• no one would know about errors or hazards
• understand how errors or hazards had arisen
• be able to address them at a systems level

Question 8

Why do some people not report (5)

Answer 8

• Not recognising hazards and safety incidents
• Too busy
• Cumbersome reporting system
• No feedback on outcomes of reports
• No evidence of learning from report

Question 9

What is a ‘human factors’ approach?

Answer 9

A human factors approach encompasses all factors that can influence people and their behaviour.
In a work context, human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work.