Lecture 16: A Culture of Patient Safety Flashcards
ISMP (Canada) The Institute for Safe Medication Practices Canada
Canadian Patient Safety Institute
what does it do?
The Institute for Safe Medication Practices Canada is an independent national not‐for‐profit organization committed to the advancement of medication safety
in all healthcare settings.
promote safe med practices
CPSI works with gov’t and organizations to improve pt safety and quality
which book breaks the silence that has surrounded medical errors and their consequences by not pointing fingers at individuals sets forth a national agenda for reducing medical errors and improving patient safety through the design of a safer health system
To Err is Human
Define culture of patient safety
A safety culture exists within an organization [when] each individual employee, regardless of their position, assumes an active role in error prevention and that role is supported by the organization.
what is described here:
view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations)
identify situations or factors likely to give rise to human error and implement systems changes
systems approach
what is described here:
personnel or parts of the health care system in direct contact with patients
administering any kind of therapy (e.g., a nurse programming an intravenous pump) or performing any aspect of care
sharp end
what is described here:
many layers of the health care system not in direct contact with patients, but which influence the personnel and equipment which do contact patients
consists of those who set policy, manage health care institutions, and design medical devices, and other people and forces, which, though removed in time and space from direct patient care, nonetheless affect how care is delivered
blunt end
what is described here:
An event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). This definition is identical to that for close call.
Need to be documented
Near miss
what is described here:
discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.
human factors engineering
what is described here:
process of avoiding such inadvertent inconsistencies by reviewing the patient’s current medication regimen and comparing it with the regimen being considered for the new setting of care.
med reconciliation
explain the medication error iceberg
reported errors are errors that cause actual harm and is the tip of the glacier
- unreported errors make up what’s below the surface\
- Incidence in health care and med errors in health system is unknown
- Many near misses not talked about
explain the swiss cheese model
protective barriers are in place such as prescription checking, patient understanding treatment, complete prescription issued, effective communication from pros when necessary, accurate check when administered
- holes in system still exist and represent weakness and active failures, latent conditions
A person problem or a system
problem?
The person approach focuses on the errors made by individuals. The reaction to these errors tends to be to name, blame and shame. Although professionals must take responsibility for their actions, blaming does not encourage a culture of reporting or learning.
In order to function safely an organisation needs to understand its risks so that it can minimise them by building in defences and safeguards. These risks can only be identified if there is commitment to an open
culture of reporting throughout the organisation.
what is the systems approach?
accepts that humans are fallible and therefore
errors can be expected to occur – and may recur regardless of the competence of individuals
- focus on the conditions and how they predispose errors
- enables system defenses to be made
define drug incident
Any preventable event that may cause or lead to inappropriate drug use or patient harm. Drug incidents may be related to the practice of pharmacists, techs, drugs, health care products, aids/devices, procedures, systems ◦ Prescribing; ◦ Order communications; ◦ Product labeling, ◦ Packaging, nomenclature; ◦ Compounding; ◦ Dispensing and distribution ◦ Administration ◦ Education, monitoring and use.
define drug error
Means an adverse drug event or a drug incident where the drug has been released to pt
Do all drug incidents need to be reported?
◦ No. You are not required to record a drug incident if it is discovered and corrected before the drug is released to the patient.
◦ However, if the drug incident is not discovered until after the drug has been released to the patient, it must be recorded as part of the quality assurance process. Recording is required even if the patient did not ingest any of the drug. However, you may wish to record these “near misses” to prevent them from recurring.
Do all adverse events need to be reported?
◦ Yes. All adverse drug events must be recorded as part of the pharmacy’s quality assurance process.
Not all adverse reactions need to be reported?
Quality Assurance: SOPs
As per Standard 1.9 of the Standards of Practice for Pharmacists and Pharmacy Technicians, each pharmacist and pharmacy technician must participate in the quality assurance process
Standard 6 of Standards for the Operation of Licensed Pharmacies
what were the results of an analysis of medication errors that reach the patient and “near misses”
in community pharmacy
◦ 131 031 events reported between study period
◦ 82% near misses
◦ 16% resulted in no harm (10.44% did not ingest; 5.87% ingested)
◦ 0.95% resulted in patient harm
in the analysis, where did most of the quality related events occur?
what are the common types of incidents?
◦ Order entry/transcription (58.7%)
◦ Preparation/Dispensing (29.3%)
◦ Prescribing (9.0%)
◦ Incorrect dose or frequency ◦ Incorrect duration of treatment ◦ Incorrect quantity ◦ Incorrect drug ◦ Incorrect strength
what strategies can be employed to prevent drug incidents?
specific for communication?
Clarify any therapy discrepancies before the medication is dispensed to the patient Barcode prescription verification Separate look‐alike drugs Point‐check policies “Show and tell” drugs avoid error prone abbrev
Communication:
◦ Discus near misses, errors with team members regularly
◦ Document clearly and effectively
◦ Provide clear communication when the care of a patient is transferred from one health care
professional to another
error prine abbrev
µg - Microgram AD, AS, AU - Right ear, left ear, each ear IN - Intranasal IT - OD, OS, OU Per os SC, SQ, sq, or sub q HS hs o.d. or OD Q.D., QD, q.d., or qd** Qhs Qn Q.O.D., QOD, q.o.d., or qod q1d q6PM, etc. SSRI SSI TIW or tiw BIW or biw UD
what should they be ?
CHECK TABLE
https://www.ismp.org/recommendations/error-prone-abbreviations-list
how can meds be used safely at home
Safe Storage and Disposal of Medications
◦ Pharmacists have a responsibility to engage in conversation with patients about the safe storage of medications in the home and about the safe disposal of unnecessary or expired medications.
◦ Advise patient on how and where they can dispose of their medications safely.
-Keep all alcohol, drugs, and poisons out of sight.
◦ Do not take your medicines in front of your child. He or she may try to do what you do.
◦ Never leave alcohol, medicines, or household products out when you are not in the room.
◦ Guests may have medicines with them. Make sure that guests keep their bags out of the reach of your child.
◦ Do not keep products like oven cleaner and dishwasher soap under the kitchen sink.
◦ Keep products in the containers they came in. Keep the original labels on them.
