Med Error, Pt Safety & TJC Flashcards
What’s done with the info collected during RCA?
Used to design changes that will hopefully prevent future errors
What’s a sentinel event?
Unexpected event involving death or serious physical or psychological injury of risk thereof
T/F? RCA is a continuous quality improvement (CQI) tool?
T
What’s Failure Mode and Effects Analysis (FMEA)?
Is a proactive method used to reduce freq and consequences of errors
What error of omission?
Leaving something out that’s needed for safety
What error of commission?
Something was done incorrectly
e.g, dispensing sulfamethoxazole for pt with a sulfa allergy
Where do u report errors in the hospital?
Pharmacy and Therapeutics (P&T) committee
+
Medication safety committee
For an inpatient when should med recon be done?
At every transition of care
Xtics of MedGuide
Contains Imp ADRs
FDA approved
Given with original script and each refill
Are abbtpreviations recommended?
They are unsafe and contribute to many medical errors
Reason for indication for use on script?
Helps pharmacist ensure appropriate prescribing and drug selection
How should measurement be kept?
Metric system only
Is it acceptable to use the term “as directed”?
No!
List the most common high-alert-drugs
Hypertonic Saline
Insulin
Heparin
KCl
Opioids
How do u reduce risk of KCl wrt storage, route of admin, label?
Centralized KCl infusions prep in the pharmacy
Stipulation that all KCl infusions must be given via a pump
Label all fluids containing K with a “Potassium Added” sticker
