Lecture 10 - Patient Safety Flashcards
Define patient safety
The reduction and mitigation of unsafe acts within the health-care system, as well as through the use of best practices shown to lead to optimal patient outcomes
Define medication error
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the drug is in control of the healthcare professional, patient, or consumer
What are the 2 types of medication errors?
1) Medication incident
2) Medication discrepancy
Define medication incident
Medication error whereby the medication has been released by the pharmacy (does not matter if patient has ingested the medication or not)
Define medication discrepancy
A medication error that is made and corrected prior to release by the pharmacy
What are the 6 steps of the prescription filling process?
1) Drop off
2) Input
3) Filling
4) Verifying/checking
5) Pick-up
6) Patient education
What are 4 instances when medication errors are more likely to happen?
1) Disorganized work space
2) Frequent interruptions & distractions
3) Emphasis on volume over quality
4) Stressed & fatigued staff
What are 6 ways to reduce medication errors?
1) Drug storage
2) Environment
3) Illegible prescriptions
4) Checking procedures
5) Patient counselling
6) Staff stress reduction
Describe how drug storage can reduce medication errors
- Store high-error drugs separately based on frequency of error
- Ensure shelves are stocked with labels facing forward
- Store look alike or sound alike drugs separately
- Store look alike labels separately
What can be considered “high error” drugs?
- Many strengths available
- High potency
- Drugs for which a reasonable dose may vary by a factor of 10
- Drugs with high potential for negative outcomes
Describe how environment can reduce medication errors
- Decrease or eliminate distractions
- Ensure a comfortable environment
- Computer systems
What are the 3 times that a prescription should be checked?
- Check the drug when it is pulled from the shelf
- Check the drug when it is labelled
- Check the drug when it is returned to the shelf
What are the additional 3 times that a prescription should be checked?
- Check DIN on stock bottle against DIN in computer
- Check when giving to the patient
- Check one prescription container is fixed and label affixed
How do you go about reporting errors in a hospital?
- When a medication incident or discrepancy occurs, it needs to be relayed to an individual in charge
- Attempt to immediately correct any medication incident
- ## Person who committed the error is required to fill out a form
How do you go about reporting errors in community?
All medication incidents must be documented on a numbered pharmacy incident report form and in a logbook
