Managing Risk 2- Syed

Question 1

T/F?

Most medication errors are the fault of INDIVIDUAL health care professionals.

Answer 1

False

- Faults are usually multi-factorial and of the SYSTEM

Question 2

What type of approach is taken when you view the FRONT end or ACTIVE end of a medication error situation?

Answer 2

Ineffective approach

Question 3

What type of approach is taken when you view the LATENT end or BLUNT end of a medication error situation ?

Answer 3

Effective approach

Question 4

The FRONT end or ACTIVE end of the medication error.

Answer 4

Looking at the first error in the medication error

Question 5

The LATENT end or BLUNT end of the medication error.

Answer 5

Looking at everything FOLLOWING the first error in the medication error

Question 6

Name the 1st five System-based Causes of Medication Weaknesses or Failures

Answer 6

1. Patient information
2. Drug information
3. Communication of drug information
4. Drug packaging, labeling, and nomenclature
5. Drug device acquisition and use

Question 7

Name the last five System-based Causes of Medication Weaknesses or Failures

Answer 7

6. Drug storage, stock, and distribution
7. Environmental factors
8. Staff competency and education
9. Patient education
10. Quality processes; and risk management

Question 8

Look-Alike/ Sound-Alike Drug error

Answer 8

When a MD writes for a medication and it looks like a different drug that what is was written for .

Question 9

What abbreviations should be avoided? (6)

Answer 9

• The abbreviation -“U” for units
• “Q” for every; QD, QID, QOD, , etc.,
• D/C (can be confused w/ discharge)
• Magnesium sulfate (MgSO4, MG)
• MTX, AZT, HCT, or HCTZ
• Morphine sulfate (MSO4, MS)

Question 10

Ambiguous Orders (8)

Answer 10

• Zeros and decimal points (no trailing zeros i.e. 100.00)
• Leading zeros
• Tablet strengths
• Liquid dosage forms
• Injectable medications (must have a dose in oppose to 5 mL w/ no dosage)
• Variable amounts
• Spacing
• Apothecary system

Question 11

What are the 2 steps in preparing and dispensing medications.

Answer 11

• Develop a system of redundant checks

- Understand the process of communication in your practice setting

Question 12

T/F?

Developing a system of redundant checks MINIMIZES the changes of discovering errors.

Answer 12

False

-MAXIMIZES

Question 13

T/F?

The more redundant checks the better.

Answer 13

True

Question 14

Knowing the steps for communication in a community or hospital pharmacy setting is related to what?

Answer 14

Understanding the process of communication in your PRACTICE SETTING

Question 15

T/F?

How many times should labels be read or checked when selecting medications.

Answer 15

3 Times

• When the product is SELECTED
• When the medication is PREPARED
• When either the PARTIALLY USED MEDICATION IS DISPOSED OF or RESTORED TO STOCK or PRODUCT PREPARATION IS COMPLETE

Question 16

When selecting medication what 3 things should we be aware of?

Answer 16

• Similar labeling and packaging
• Look- alike names
• confirmation bias

Question 17

T/F?

When preparing sterile admixtures the potential for grave errors are DECREASED.

Answer 17

False

-Increased

Question 18

Why are potential grave errors increased for sterile admixture preparation (2)?

Answer 18

• Patients are sicker

- Most injectable solutions are clear, colorless, and water-based

Question 19

What requires independent double-checks by two staff members?

Answer 19

Sterile admixture preparation

Question 20

Standardizing doses and concentrations, are needed for what 5 critical care drugs?

Answer 20

• Heparin
• Dobutamine
• Insulin
• Dopamine
• Morphine

Question 21

T/F?
UNIT-DOSE SYSTEMS and STANDARDIZING DOSES and CONCENTRATIONS help to minimize calculation errors by avoiding the need to for calculations in the first place.

Answer 21

True

Question 22

Unit-dose systems in the nursing units?

Answer 22

Standardized

dosage charts

Question 23

Unit- dose systems in the pharmacy?

Answer 23

Standardized formulations

Question 24

What plays a significant role in catching medication errors before they occur? (3)

Answer 24

Patient Counseling and Education

• Direct patient education
• Health-care literacy
• Patient compliance

Question 25

Name the error reduction strategies from high to low leverage. (9)

Answer 25

• Fail-safes and constrains
• Forcing functions
• Automation and computerization
• Standardization
• Redundancies
• Reminders and checklists
• Rules and policies
• Education and information
• Suggestions to be more careful or vigilant

Question 26

_____ ______ programs are important in preventing errors.

Answer 26

Quality assurance

Question 27

T/F?

Errors WILL be eliminated completely.

Answer 27

False

- WILL NEVER

Question 28

Working on _______ errors and safety issues provides the best outcomes in the safest environment possible.

Answer 28

REDUCING ERRORS and SAFETY ISSUES

Question 29

T/F?
“High leverage” strategies, such as CONSTRAINTS and FORCING FUNCTIONS, are more powerful because they focus on changes to the system in which individuals operate.

Answer 29

True

Question 30

FMEA (failure mode and effects analysis)

Answer 30

• used to EXAMINE the USES of new PRODUCTS to determine points of potential FAILURES and their EFFECTS BEFORE any ERROR actually happens

Question 31

T/F?

FMEA is a proactive process used to carefully and systematically evaluate vulnerable areas or processes.

Answer 31

True

Question 32

T/F?

You are not AT RISK when filling out medication error forms.

Answer 32

True

-because they are apart of the CQI process and they cannot be subpoenaed.