Managing Risk 2- Syed Flashcards
T/F?
Most medication errors are the fault of INDIVIDUAL health care professionals.
False
- Faults are usually multi-factorial and of the SYSTEM
What type of approach is taken when you view the FRONT end or ACTIVE end of a medication error situation?
Ineffective approach
What type of approach is taken when you view the LATENT end or BLUNT end of a medication error situation ?
Effective approach
The FRONT end or ACTIVE end of the medication error.
Looking at the first error in the medication error
The LATENT end or BLUNT end of the medication error.
Looking at everything FOLLOWING the first error in the medication error
Name the 1st five System-based Causes of Medication Weaknesses or Failures
- Patient information
- Drug information
- Communication of drug information
- Drug packaging, labeling, and nomenclature
- Drug device acquisition and use
Name the last five System-based Causes of Medication Weaknesses or Failures
- Drug storage, stock, and distribution
- Environmental factors
- Staff competency and education
- Patient education
- Quality processes; and risk management
Look-Alike/ Sound-Alike Drug error
When a MD writes for a medication and it looks like a different drug that what is was written for .
What abbreviations should be avoided? (6)
- 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)
Ambiguous Orders (8)
- 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
What are the 2 steps in preparing and dispensing medications.
- Develop a system of redundant checks
- Understand the process of communication in your practice setting
T/F?
Developing a system of redundant checks MINIMIZES the changes of discovering errors.
False
-MAXIMIZES
T/F?
The more redundant checks the better.
True
Knowing the steps for communication in a community or hospital pharmacy setting is related to what?
Understanding the process of communication in your PRACTICE SETTING
T/F?
How many times should labels be read or checked when selecting medications.
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
When selecting medication what 3 things should we be aware of?
- Similar labeling and packaging
- Look- alike names
- confirmation bias
T/F?
When preparing sterile admixtures the potential for grave errors are DECREASED.
False
-Increased
Why are potential grave errors increased for sterile admixture preparation (2)?
- Patients are sicker
- Most injectable solutions are clear, colorless, and water-based
What requires independent double-checks by two staff members?
Sterile admixture preparation
Standardizing doses and concentrations, are needed for what 5 critical care drugs?
- Heparin
- Dobutamine
- Insulin
- Dopamine
- Morphine
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.
True
Unit-dose systems in the nursing units?
Standardized
dosage charts
Unit- dose systems in the pharmacy?
Standardized formulations
What plays a significant role in catching medication errors before they occur? (3)
Patient Counseling and Education
- Direct patient education
- Health-care literacy
- Patient compliance
Name the error reduction strategies from high to low leverage. (9)
- 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
_____ ______ programs are important in preventing errors.
Quality assurance
T/F?
Errors WILL be eliminated completely.
False
- WILL NEVER
Working on _______ errors and safety issues provides the best outcomes in the safest environment possible.
REDUCING ERRORS and SAFETY ISSUES
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.
True
FMEA (failure mode and effects analysis)
- used to EXAMINE the USES of new PRODUCTS to determine points of potential FAILURES and their EFFECTS BEFORE any ERROR actually happens
T/F?
FMEA is a proactive process used to carefully and systematically evaluate vulnerable areas or processes.
True
T/F?
You are not AT RISK when filling out medication error forms.
True
-because they are apart of the CQI process and they cannot be subpoenaed.
