LESSON 5: Medication Safety Flashcards
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”
Medication Errors
According to National Coordinating Council for Medication Error Reporting and Prevention, such events (Medication Error) may be related to:
professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use
It has been reported that __________ are among the commonly encountered medical problems in clinical practice, one of these is medication error.
Adverse drug effects
Medication errors can lead to _________ if not recognized or managed accordingly.
Fatalities
Generally occur as unsafe acts which are committed in the background of a potential hazard. This is a result of __________
System failure
Proposed by James Reason in 2000. He said that ideal system is analogous to a stack of slices of swiss
cheese.
Swiss Cheese Model of Accident Causation
In the swiss cheese model, these are considered as opportunities for a process to fail.
Holes
In the swiss cheese model, these are defensive layers in the process. It is a defense against potential error impacting the outcome
Each slices
In the swiss cheese model, this may allow a problem to pass through a whole in one layer.
Error
In the swiss cheese model, in the succeeding layers, holes are in _________ such that the problem is caught and addressed.
different places
In the swiss cheese model, if a hole in one layer coincides with the holes in the next layers, the problem is allowed to _______ and can eventually lead to an adverse outcome.
pass through
A general type of error that involves administering a drug without having established whether a potential adverse event or reaction will occur.
Ex. When one gives penicillin without checking whether the patient has a history of allergy or not.
Knowledge-based errors
A general type of error that involves using a bad rule or misapplying a good rule.
Ex. Injecting diclofenac in lateral thigh rather than in buttocks.
Rule-based errors
A general type of error that involves slips in which certain practices were done incorrectly.
Ex. Dispensing a drug Leponex (Generic: Clozapine), an
atypical antipsychotic medication, instead of Ceporex (Generic: Cefalexin), a cephalosporin antibiotic, or picking up a bottle of Gabapentin, an anticonvulsant for Gemfibrozil, a lipid-regulating drug.
Action-based errors
Medication errors can occur in every of the ____________.
Medication process
A general type of error that involves lapses in which steps in the medication process are missed.
Ex. Failure to administer antibiotics prior to surgical operation.
Memory-based errors
A specific type of error that includes Incorrect drug selection (based on indications, contraindications, known allergies, existing drug therapy, and other factors), dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician (or other legitimate prescriber); illegible prescriptions or medication orders that lead to errors that reach the patient.
Ex. [Case Study 1] Patient received a total of 16,000 mg/m2 instead of a 4000 mg/m2, an incorrect drug dose.
Prescribing errors
A specific type of error that includes an error in drug dispensing (type and dose) as a result of outdated or incorrect drug reference information, poor work environment, suboptimal packaging, labeling of products, interpretation of prescriptions, failure to double-check orders.
Ex. [Case Study 2] The prescription drug name Avandia (Rosiglitazone maleate) was incorrectly interpreted as Coumadin (Warfarin) by the pharmacist.
Dispensing errors
A specific type of error that involves a medication administration error which includes administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient, i.e., one or more dosage units in addition to those that were ordered.
Improper dose error
A specific type of error that involves a medication administration error which includes failure to administer an ordered dose to a patient before the next scheduled dose, if any.
Omission error
A specific type of error that involves a medication administration error which includes administration of medication outside a predefined time interval from its scheduled administration time (this interval should be established by each individual health care facility)
Wrong time error
A specific type of error that involves a medication administration error which includes inappropriate procedure or improper technique in the administration of a drug.
Ex. Giving Vitamin K1 as a bolus instead of as a push
Wrong administration-technique error
A specific type of error that involves a medication administration error which includes administration to the patient of medication not authorized by a legitimate prescriber for the patient.
Ex. Administration of an over-the-counter medication which was not previously approved by the attending physician or a drug which has no proven therapeutic indication.
Unauthorized drug error
A specific type of error that involves a medication administration error which includes administration to the patient of a drug product in a different dosage form than ordered by the prescriber.
EX. Giving the drug through parenteral form rather than in oral preparation.
Wrong dosage-form error
A specific type of error that involves a medication administration error which includes incorrectly formulated drug product or manipulated before administration and incorrect dilution or reconstitution, mixing drugs that are physically or chemically incompatible.
Wrong drug-preparation error
A specific type of error that involves a medication administration error which includes administration of a drug that has expired or for which the physical or chemical dosage-form integrity has been compromised.
Ex. Administration of a drug 3 months after expiration date.
Deteriorated drug error
It’s very important that patients are provided with appropriate information and advice because if they are not given so, ___________ may happen.
Ex.
Case 4: 45-year old female on methotrexate stopped taking the medication because of vomiting and diarrhea
Case 5: 54-year old male, maintained on warfarin, developed bleeding. Protimedetermination showed an INR of 7 which is prolonged.
Patient adherence errors
A specific type of error that involves a patient adherence error which includes inappropriate patient behavior regarding adherence to a prescribed medication regimen.
Compliance error
