Lecture 9: Medication Safety/Medication Shortages

Question 1

What is a common misconception of medication errors?

Answer 1

It is a common misconception that many medication errors are made by incompetent health care professionals that hve history of making several errors over time. In general, it is RARE for a healthcare professional to make multiple medication errors

Question 2

What are 5 major catergories in the medication use process?

Answer 2

1. prescribing (56%)
2. documenting (6%)
3. dispensing (4%)
4. administering (34%)
5. monitoring

Question 3

Which of the 5 major catergories of the medication use process produces highest rate of error?

Answer 3

Prescribing!

Question 4

What does the ISMP mention about the medication use process?

Answer 4

• Institute for Safe Medication Practices. State that the avg number of steps in medication use
  process is 40.

Question 5

What happens whenever a medication error occurs?

Answer 5

Root Cause Analysis
*After a medication error has already happened

Question 6

What does Root Cause Analysis mainly focus on?

Answer 6

1. the systems and processes to determine why an error occured
   *should NOT focus on individual performance issues

Question 7

What analysis is used to proactively prevent medication errors?

Answer 7

Failure Mode and Effects Analysis (FMEA)

Question 8

Which analysis is conducted BEFORE a medication error occurs?

Answer 8

Failure Mode and Effects Analysis (FMEA)

Question 9

What is the primary goal of FMEA?

Answer 9

identify areas of potential fialure in the medication use process at your pharmacy or institution (risk-reduction strategy)

Question 10

This source of medication error is one of the most common and has the potential for the MOST harm.

Answer 10

the inapproriate use of decimals
1. never use a trailing zero (could lead to a 10-fold increase in dosing b/c the decimal point can be missed)
2. Always use a leading zero (10-fold dosing error can occur as well)

Question 11

For patient safety in verbal orders, how should you pronounce digits?

Answer 11

Pronounce digits separately when providing a strength or dose.

For example: lisinopril 2mg should be communicated, “Lisinopril twenty milligrams that’s two zero milligrams”

Question 12

How many times should you check a prescription against the prescription?

Answer 12

3 times

Question 13

What are 3 medication error preventions that Dr. Sullivan mentions?

Answer 13

1. never use trailing zeros, always use leading zeros
2. check prescription against prescription label at least 3 times
3. Have a pharmacist verify any calculations you do. Do it independently

Question 14

What are the 5 Rs for medication error prevention?

Answer 14

1. right patient
2. right drug
3. right time
4. right dose
5. right route

Question 15

When you ask the pharmacist to check calculations should you ask them to do it independently or give them your work to check?

Answer 15

Ask them to do it independently

Question 16

Can pharmacists affect all categories of medication process?

Answer 16

YES!