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
Whats REMS?
FDA program that requires specified training and various restrictions on certain drugs
Common types of hospital (Nosocomial) Acquired hospital?
UTI
Blood stream inf (.from IV, esp central lines, and catheters)
Surgical site infections
Decubitus ulcers
Hepatitis
C.difficle, other GI inf
Pneumonia (mostly due to ventilation), bronchitis
In what grp of pt is contact precautions recommended?
Pts colonized with MRSA and VRE
In what grp of pt is airborne precautions recommended?
Pts with rubella virus (measles), varicella virus (chicken pox) or M.tuberculosis
Should u recap needles b4 discarding?
No!
How does the air flow in vertical flow hoods (also called Biological safety cabinets/ chemo hoods)
Top down
Uses of vertical hood?
Chemo
And other hazardous meds
What’s Laminar flow?
Air moving in an uninterrupted, constant stream
What does HEPA filter remove?
99.97% of all air particles 0.3 mm or larger
How much space is left to make front edge of the hood clear?
6 inches
What’s a root cause analysis (RCA)?
RCA is a retrospective investigation of an event that already occurred
