IPC exam II Flashcards

Question

Which Apps can you recommend?

Answer 1

Safe to recommend an app developed/adopted by the CDC for patients Safe to use an app developed/adopted by the CDC to look up information yourself Safe to recommend an FDA-approved app, if applicable to your patient Example: Endeavorrx® for ADHD Safe to recommend an FDA-approved digital device, If applicable to your patient Example: Auvi-Q Safe to recommend not using a digital health tool for an intervention that a guideline does not recommend Example: earwax cleaning tools Otherwise, further appraisal of the app is required to determine benefits & potential harm

Answer 2

Consumer/General Public Apps: CDC Health IQ Example questions: - Do you know the minimum SPF needed to protect yourself from the sun’s harmful rays? - How many seconds you should wash your hands to kill germs? Health Care Provider/Clinician Apps - Example: Contraception App, Vaccine Schedule App https://www.cdc.gov/digital-social-media-tools/mobile/applications/healthiq/index.html

Answer 3

Medscape: one-stop-shop resource (free after you create an account) Drugs@FDA Express (free mobile version of FDA’s online database information) Merck Manual Professional: regularly updated articles, drug information, illustrations (free) Pharmacist’s Letter: great charts, drug comparisons, monthly newsletters (free for MCPHS students; create an account through the MCPHS library website) Lexicomp, Micromedex (with paid subscription)

Answer 4

Growing pharmacist role/services - Essential: prescription dispensing; ex: CVS app, Walgreens app, etc. - Advanced: medication use reviews (MURs) (structured review of prescribing, dispensing, and patient use of medications) - Frees up pharmacist’s time spent on administrative work Availability of apps on portable devices ↓ time to carry out a service or task: easier to type/search than flipping through papers, updated information - Ex: rapidly access relevant literature Inform the decision-making process through clinical decision support Facilitate pharmacist/staff/patient education through educational apps

Answer 5

To Err Is Human – 1999 Institute of Medicine (IOM) report - Up to 98,000 patients harmed annually by healthcare - Preventable medical errors - Permanent injury - Hospital admissions - ↑ length of stay - Death - “First, do no harm” Medical errors usually do not result from: - Recklessness - One individual - Actions of a particular group Medical errors usually result from: - Faulty systems - Faulty processes - Faulty conditions

Answer 6

Medication Safety: “Freedom from accidental or preventable injuries during the course of medication use” Patient Safety: “Freedom from accidental or preventable injuries produced by medical care”

Answer 7

Evaluating the medication use process Identify areas of weakness Where can the process fail? Re-design processes Make it harder to do the wrong thing Make it easier to do the right thing Assess each medication error Identify contributing factors Learn from each event

Answer 8

can lead to: Side effects (SEs) or adverse events/reactions (AEs) Adverse drug reactions (ADRs) Medication errors (MEs)

Answer 9

Any unexpected, unintended, undesired, or excessive response to a drug that: - Requires drug discontinuation - Requires changing the drug - Requires a dose change - Requires hospital admission - Increases length of stay - Requires supportive therapy - Complicates diagnosis - Results in temporary or permanent Harm - Disability - Death - Involves routine doses

Answer 10

Incidence and severity of adverse drug reactions (ADRs) - Unpredictable - Varies depending upon Hospital size Hospital type Patient population Drugs used ADR definition used Can be extremely costly; > $2,000 per patient per event - Increase length of stay by 2-3 days 2-fold increased risk of death An estimated 5 – 20% of hospitalized patients experience an ADR 4th to 6th leading cause of death in US

Answer 11

Side effects - These are expected, predictable, well-known reactions, resulting in little or no change in management Drug withdrawal Drug abuse Accidental poisoning/overdose

Answer 12

Cefazolin (antibiotic) 1G IV Q8H ordered for cellulitis. The patient develops severe hives-like reactions. Cefazolin was discontinued and vancomycin (an antibiotic of a different class) started.

Answer 13

A patient is started on a usual dose of the beta blocker, metoprolol. A few hours later, the patient faints and is rushed to the hospital. The patient’s heart rate was found to be 42 and the physicians administer atropine to increase the heart rate.

Answer 14

Encourages ADR surveillance Monitors drug safety in our patient population Promotes education about potential ADRs Identifies problems leading to ADRs

Answer 15

External - FDA MedWatch - Voluntary form FDA 3500 - Can be completed online at www.fda.gov/medwatch/ - Used for severe or unusual adverse events - Vaccines excluded FDA Adverse Event Reporting System (FAERS) Vaccines adverse event reporting system (VAERS) https://vaers.hhs.gov/reportevent.html Internal - Institutional ADR reporting system

Answer 16

Reporting/ Analysis/ Dissemination Reporting may prompt: - Modification in how the drug is used - Change in labeling - Modification in product design - Communication of the issue - Leads to increased patient safety

Answer 17

immediate release previous dosing: 10mg immediately before bedtime new dosing rec: - women: 5mg immediately before bedtime - men: 10mg consider starting at 5mg extended release previously dosing: 12.5mg immediately before bedtime new dosing: - women: 6.25mg immediately before bedtime - men: 12.5mg consider starting at 6.25mg Low-dose sublingual tablet previous dosing: - women: 1.75mg taken once per night - men: 3.5mg taken once per night

Answer 18

may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

Answer 19

$5,857: Cost per preventable error in hospitals 7,000: Number of US deaths from medication errors each year $17 billion: Estimated US annual cost of preventable errors

Answer 20

Medications have ↑’d risk of causing significant patient harm when used in error Errors not more common The impact (patient harm) of error is greater Examples: anticoagulants, insulin, IV sedation, opiates

Answer 21

losec changed to Prilosec celebra changed to Celebrex

Answer 22

A: Circumstances or events that can cause error Example: Look-alike, sound-alike medications stored near each other B: An error occurred that did not reach the patient; “Near miss” Example: Medication labeled incorrectly but caught in the pharmacy C: An error occurred that reached the patient but did not cause patient harm Example: Docusate sodium 100 mg PO was given to the incorrect patient x1 dose

Answer 23

D: An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm Example: Oxycodone 20 mg was given to a patient who was prescribed oxycodone 5 mg; the patient was monitored for sedation but did not experience any adverse effects or excess sedation E: An error occurred that may have contributed to or resulted in temporary patient harm and required intervention Example: Patient was not prescribed his home antihypertensive medications when admitted to the hospital and later needed urgent treatment for elevated BP

Answer 24

F: An error occurred that may have contributed to or resulted in temporary patient harm and required initial or prolonged hospitalization Example: A patient with heart failure missed 2 doses of furosemide and became fluid-overloaded, requiring prolonged hospitalization G: An error occurred that may have contributed to or resulted in permanent patient harm Example: A patient missed 3 doses of levetiracetam and had a seizure that led to a disability

Answer 25

H: An error occurred that required intervention necessary to sustain life Example: Patient receives oral phenytoin suspension intravenously and goes into cardiac arrest but is subsequently resuscitated I: An error occurred that may have contributed to or resulted in the patient’s death Example: A patient is given 800 mg of clozapine intended for another patient, has a seizure, and passes away

Answer 26

Type D - moniDoring

Answer 27

Type B - But I caught it

Answer 28

Type C - patient got it but Caused no harm

Answer 29

Recurrent patterns so we can predict them

Answer 30

How errors happen Many layers of defense Opportunities for failure

Answer 31

Person approach (Culture of Blame) - Human failings - “bad things happen to bad people” - Punitive (does not promote reporting errors) - Result is recurrent errors System Approach (Culture of Safety or Just Culture) - Errors are expected - Understand how errors happen - Learn from error events - Non-punitive (encourages reporting errors) - Result is a safer environment

Answer 32

some holes due to active failures hazards go right through it other holes due to latent conditions successive layers of defenses, barriers & safeguards

Answer 33

People-Based - Mistakes - Memory lapses - Procedure violations active System-based - Understaffing - Inexperience - Inadequate equipment latent

Answer 34

prescribing dispensing administration monitoring

Answer 35

Similar medication names Medications with multiple brand names Stocking medications with multiple concentrations Environment Technology

Answer 36

FDA reviews drug names before marketing About 100 healthcare professionals volunteer to assist with reviews 1/3 of all proposed drug names get rejected Some names even get changed post-marketing: - Losec changed to Prilosec - Losec confused with Lasix Brtintellix changed to Trintellix (vortioxetine) - Brintellix confused with Brillinta

Answer 37

Examples Clonidine 0.5 mg and Klonopin 0.5 mg Celexa and Celebrex Risperidone and Ropinirole Dexamethasone and Dexmedetomidine

Answer 38

Bupropion: Wellbutrin SR Wellbutrin XL Budeprion SR and XL Aplenzin Lamivudine: Epivir Epivir HBV Finasteride: Propecia Proscar Sildenafil: Viagra Revatio

Answer 39

Workload Interruptions Light Noise Heat/ humidity Phones Cluttered areas

Answer 40

Different types of IV pumps Too many lines Technology that is too slow or too difficult

Answer 41

Illegible handwriting Using error-prone (dangerous) abbreviations Omitting important information on prescription Erroneous calculations Selecting the wrong drug (electronically or physically)

Answer 42

MD orders heparin drip one RPh short today heparin and hespan are stocked on the same shelf Tech pulls a bag of Hespan off the shelf and labels it as Heparin Minimal training for new technicians Heparin requires a 2nd pharmacist check; is only checked by one Pharmacist does not catch error when checking Medication Error

Answer 43

Preventing errors by: Being more careful Trying harder Providing education Has not worked! Must use safe design principles to reduce likelihood of error

Answer 44

Simplify Standardize Reduce variation Use forcing functions and constraints Use redundancies Avoid reliance on memory Automate carefully

Answer 45

Taking steps out of a process If too complicated… Too much time to learn it correctly Too many opportunities for confusion Users will find another way: “Workarounds”

Answer 46

Easy to do the right thing Impossible to do the wrong thing Creates a “hard stop”: Must change your action

Answer 47

Checklists Standardized order forms

Answer 48

Medication lists - Physician order forms (paper or electronic) Telephone/verbal orders or prescriptions - Transferring information - Refer to the handout!

Answer 49

Frequently used & misinterpreted Have caused patient harm Prohibited for use in ANY part of the medical record in the hospital setting - Includes written and electronic records Also part of The Joint Commission “Do Not Use” List

Answer 50

do not used U IU QD, Q.D, QOD, Q.O.D. lack of leading zeros drug abbreviations: MS, MSO4, MgSO4 use Unit international unit daily or every other day no trailing zero morphine sulfate magnesium sulfate

Answer 51

QD - Can be mistaken for QID or QOD Write out “daily”

Answer 52

QOD - Can be mistaken for QD or QID Write out “every other day”

Answer 53

U for unit - Can be mistaken for a number (4 or 0) or for cc Write out “unit” or “units” IU for international units - Can be mistaken as IV or 10 Write out “international units”

Answer 54

Trailing zero after decimal point (1.0 mg) Decimal point can be missed resulting in overdoses (1.0 mg read as 10 mg) Never write a zero by itself after a decimal point Exception: when trailing zero is required to demonstrate the level of precision of the value being reported, such as for lab results,imaging studies, or catheter/tube sizes

Answer 55

No leading zero before a decimal dose (.5 mg) - Decimal point can be missed resulting in overdoses (.5 mg read as 5 mg) Always use a zero before the decimal point (0.5 mg)

Answer 56

MSO4 MS MgSO4 - Can be mistaken for each other Write out the complete drug name Morphine sulfate Magnesium sulfate

Answer 57

BEFORE Zolpidem 5mg PO QHS prn Colchicine .6 mg PO BID Metoprolol tartrate 25 mg 1/2 tablet PO BID Atorvastain 40 mg PO daily PCN 500 mg PO Q6H APAP prn

Answer 58

Separate easily mistaken drugs Example: Cortisporin Otic vs. Cortisporin Ophthalmic, Heparin vs. Hespan Shelves Automated dispensing machines Identify drugs that are more likely to be misfilled Identify “red flag” (high alert medications) - Use extra caution Don’t GUESS or become a mind reader!

Answer 59

Use a structured/standardized process when checking EVERY time Triple-check your work When in doubt, ask!

Answer 60

Don’t think of medication safety only as a specialty area Make it part of your practice Acute and chronic care Don’t take anything for granted Check, check, and check again! Many factors contribute to an error Learn from each event Prevent similar events Use safe design principles How can you promote safety?

Answer 61

registration provider - MD, NP, PA Nursing - RN, LPN

Answer 62

Hemoglobin hematocrit White blood cells (WBCs) Red blood cells (RBCs) - Mean corpuscular volume (MCV) - Mean corpuscular hemoglobin (MCH) - Mean corpuscular hemoglobin concentration (MCHC) Platelets (Plt)

Answer 63

BMP or Chem-7: Sodium (Na+) Potassium (K+) Chloride (Cl-) Bicarbonate (HCO3-) Blood urea nitrogen (BUN) Creatinine (SCr) Glucose (Glu) Plus: Albumin Alkaline phosphatase (ALP) Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Total bilirubin Calcium

Answer 64

stay in ED room cath lab x-ray MRI CT scan OR yellow pod inpatient hospital bed

Answer 65

Magnetic Resonance Imaging (MRI) Computerized Tomography

Answer 66

Catheterization Laboratory (Cath Lab) Med/Surg Hospital Room

Answer 67

PT OT RT Dietary social work microbiologist pharmacy

Answer 68

Customers - Patient, families, caregivers, IPE team members Medical Record Access - Detailed history, lab, and test results Interprofessional Collaboration Expected - Healthcare team is readily accessible and all team players are expected to work together Tasks and Disease States - Acute illnesses – rapid changes in patient status, medications used, dosage forms, packaging, labeling, cart fill, automated dispensing cabinets

Answer 69

Two main models. There has been a shift from centralized model to decentralized model over the last few decades. Centralized - Pharmacist work in the pharmacy Decentralized - Pharmacist work throughout on patient care floors and in the pharmacy space

Answer 70

Staff/Clinical Pharmacist Tasks: - Medication order review and verification - Patient care rounds* - Evaluate patient medical record for medication related problems - Medication Information Service - Compounding – sterile and nonsterile - Policy and protocol development - Consult service for complex medication regimens Ex. Warfarin, vancomycin, or Total Parental Nutrition (TPN) dosing and monitoring Medication Reconciliation* Trauma/Code Response Team* Pharmacy Technicians Tasks - Compounding – sterile and nonsterile - Stocking medications Automated Dispensing Cabinets (ADC) - Kits or trays for codes or surgery - Answering phones and triaging requests - Packaging medications – unit dose packaging - Medication Reconciliation

Answer 71

pharmacy director

Answer 72

Examples of workstations: Fill area IV admixture area Sterile non-hazardous Sterile hazardous Nonsterile Compounding Pharmacist workstations Packing area Controlled Substance storage

Answer 73

electronic order

Answer 74

Institutional pharmacy is similar and yet very different than other types of pharmacy settings. Understanding what the patient experiences and how each team member in the care process contributes better helps you understand your role as a pharmacist. Through the next several lectures we are going to take a deeper dive into medication use processing and skill sets used in an institutional pharmacy setting.

Answer 75

Increases efficiency Decreases errors Saves money Improves patient outcomes good outcome

Answer 76

Procurement Storage and Stocking Distribution - Ordering, Review, Preparation, Delivery Administration Education

Answer 77

Procurement a.k.a. Acquisition – the act of obtaining goods or services

Answer 78

Automated Dispensing Cabinet (ADC) - pyxis medstation Automated Storage - medication carousel

Answer 79

Med/Surge Nursing Unit Cath Lab

Answer 80

electronic med record

Answer 81

Perform Drug Utilization Review (DUR): Patient Allergies Medication Duplication Drug-Disease Interaction Drug-Drug Interaction Drug-Food Interaction Correct Dosing: Appropriate for age, weight, renal, and hepatic function Frequency Route of administration Correct dosage form for route of administration Correct rate of infusion and access type (IV medications) Appropriate labs have been drawn prior to starting medication Appropriate monitoring parameters have been ordered

Answer 82

IV Room - Sterile Preparation Non Sterile Preparation

Answer 83

For sterile and nonsterile compounding: - Review all ingredients – before compounding. - Review the steps of the compounding process. - Verification of the final products after compounding. Intravenous Medication Example: - Order: Magnesium Sulfate 2 g in NS IV Once

Answer 84

Medication can be dispensed to nurses from ADC - Distribution - pharmacy responsible for stocking ADC Medication can be dispensed from the central pharmacy - distribution - tube system, robot or human delivery Medication needs to be compounded - distribution - tube system, robot, or Human delivery

Answer 85

Pneumatic Tube System https://www.youtube.com/watch?v=8AyqGwALd0g Pros - Fast delivery - Less people needed in the delivery process - automated Cons - Not everything can be delivered this way – proteins will denature, glass can break - Subject to human error in terms of delivery – select the wrong location – delivery is delayed

Answer 86

acquire the medication from the pharmacy preparation of medication for administration double-check med and patient educate the patient - drug name, purpose, common side effects administer the medication

Answer 87

There are many steps in the medication use process. Pharmacists are involved in every step of the institutional setting. A good medication use process increases efficiency, decreases medication errors, saves money, and improves patient outcomes.

Answer 88

Patient Name, location of care, DOB, broad overview of alerts, MRN (medical record number)

Answer 89

Major Section of the dark side menu: health, pharmacy, account

Answer 90

Temp Pulse Respiratory Rate (RR) BP Pulse oximetry (a.k.a. pulse ox) Pain – number of different scales that can be used Growth – height and weight – be careful of the units! Glucose Intake and output (a.k.a. Ins and outs) Quick survey – this is a brief assessment of all of the body systems of the patient – (a.k.a. Review of Systems – ROS)

Answer 91

Category examples: Medications, Labs, Diet, Consultation, Procedures Order Item Frequency Status - - - When

Answer 92

ABG (Air Blood Gas) BMP Complete Metabolic Panel CBC with differential CMP (Comprehensive Metabolic Profile) Creatine Kinase (ck) Isoenzymes Electrolytes Lipid Profile Liver Panel (Liver Function Panel) Urinalysis Coagulation Screen Cerebrospinal Fluid (CSF) Many more

Answer 93

Patient address Language Occupation Emergency Contact PCP (primary care provider) Rendering Provider

Answer 94

Movement of patient care from one place to another. Examples: Department to Department – Surgery to the patient floor, emergency room to the patient floor Change of Shift – day to night Inpatient to Outpatient – hospital discharge to primary care physician Outpatient to Inpatient – primary care physician to hospital inpatient Specialist (cardiology, infectious disease, etc.) to Primary Care Primary Care to Specialist (cardiology, infection disease, etc.)

Answer 95

Preventable medication errors impact 7 million patients in the US annually. 400,000 preventable deaths 1.5 million patients with serious harm Prolonged hospitalizations and/or hospital readmission  increased healthcare costs The annual cost of these medication errors is about $21 billion dollars a year. About 30% of hospitalized patients have a discrepancy on their discharge medication list when they leave the hospital. This leads to adverse drug reactions, drug-drug interactions, and health risks to the patients. This is a preventable medication error

Answer 96

Readmissions Adverse drug reactions Medication errors Omission, duplication, drug-drug interactions Communication between healthcare providers Follow-up and coordination of care Multiple providers prescribing medication

Answer 97

Formal process Obtaining the most complete and accurate list of a patient’s medication Comparing medication orders to all of the medication the patient is currently taking and resolving any discrepancies Goal To avoid medication errors including omissions, duplications, incorrect dosing or timing, and drug interactions

Answer 98

Obtain a baseline medication history Interview the patient/caregiver Confirm the accuracy of interview information update the patient's medical record communication info. to the healthcare team

Answer 99

Specific Medication Questions: Name Strength Dosage form and route of administration Directions When was your last dose? What time of day do you take this medication? Additional questions to ask your patient: Are you taking any over-the-counter medications? Are you taking any herbal products? Are you taking any vitamins?

Answer 100

Medication name Reaction Age of Reaction

Answer 101

How to start – introduce yourself: Hi, my name is Jen. I am a pharmacist here at MCPHS hospital. I have a few questions for you about the medications you take at home and your medication allergies. Is now an OK time to talk with you about these? - This question asks the patient for permission and their time. Can you please confirm your name and date of birth? - This question provides a confirmation you are talking to the correct patient.

Answer 102

How can you confirm what the patient is telling us? Or what if the patient doesn’t know the answer to our questions?

Answer 103

How can you confirm what the patient is telling me? You contact the pharmacy and make the following request: Hi, my name is Jen Towle. I work for MCPHS Hospital and we have a mutual patient. I would like to get a copy of Jerry Jackson’s medication profile. The patient's date of birth is 11/16/1955. Thank you. You can then compare the list you got from the patient against the list you received from the pharmacy to be sure they match. If there is a discrepancy you will sometimes need to go back to the patient to ask for further clarification.

Answer 104

Pharmacists can play a unique and important role in helping to improve the current system. Improvements in transitions of care will lead to improved patient care and outcomes. Your goal is to attempt to get the most accurate list of medications the patient is currently taking and how they are taking them. Along with any other medication history that helps treat your patient. A good quality medication reconciliation prevents medication errors.

Answer 105

* Tdap for every pregnancy, ideally during gestational weeks 27 to 36 weeks gestation * Inactivated Influenza vaccine * COVID‐19 vaccine – ensure patient is fully vaccinated * RSVPreF (Abrysvo) during gestational weeks 32 to 36 in RSV season Bivalent

Answer 106

MMR, varicella, influenza, rotavirus, typhoid are live Recombinant modified vaccinia anakara, canaryox (alvac), shingles, HPV, meningitis, hep B

Answer 107

Immunocompromised, elderly, pregnant women, ppl with anaphylactic allergies

Answer 108

Adjuvants help the body to produce an immune response strong enough to protect the person from the disease he or she is being vaccinated against. an ingredient used in some vaccines that helps create a stronger immune response in people receiving the vaccine. In other words, adjuvants help vaccines work better.

Answer 109

Data show this does not cause any adverse effects * Consider how many pathogens are on the surfaces you touch every day * The immune system is designed to handle it! * Delaying vaccines increases: - Risks of infection and outbreaks - Number of appointments/health care system burden - Likelihood that the vaccine schedule will not be completed