Med Safety

Question 1

what is ‘Just Culture’ in patient safety

Answer 1

• seeks to create a system of workplace justice that fostered open reporting, while simultaneously holding people appropriately accountable for their actions

Question 2

benefit of ‘Just Culture’ in patient safety

Answer 2

1. creates psychological safety for staff to report errors
2. uses common language to consistently and fairly evaluate human behavior
3. shift focus from errors and outcomes to system designs and behavioral choices
4. creates accountability, not punitive nor blame-free

Question 3

what is side effect

Answer 3

a known effect, other than primarily intended, relating to the pharmacological properties of a medication (eg. n&v)

Question 4

what is ADR

Answer 4

any response to a meds that is noxious and unintended (Eg. hypersensitivity)

Question 5

what is medication error

Answer 5

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

can lead to:

1. adverse event (pt is harmed)
2. near miss (pt almost harmed)
3. neither harm nor potential for harm

Question 6

what is a near miss event

Answer 6

an event or situation that could have been resulted in med error but did not (usually by chance or though timely intervention)

• if near miss is ignored may lead to med errors reaching pt

Question 7

what is an adverse drug event

Answer 7

an injury due to medication

• may be preventable (due to medication error)
• may not be preventable (ADR or SE of meds)

Question 8

steps involved in patient using medication

Answer 8

1. prescribing
2. preparation and dispensing
3. administration (highest error rate)
4. monitoring

Question 9

errors in administration

Answer 9

1. wrong patient, drug, dose, time, route
2. omission, failure to administer
3. inadequate documentation

Question 10

errors in monitoring

Answer 10

1. lack of monitoring for ADR
2. drug not ceased if not working
3. drug ceased before complete course
4. drug levels not measured or follow up (@ right time)
5. communication error

Question 11

patient at higher risk of med errors

Answer 11

1. multiple meds or health conditions
2. with more than 1 doctor
3. specific conditions (renal/ hepatic impairment, preg)
4. cannot communicate well
5. not actively in charge of their own meds
6. children/babies (where dose cal is required)

Question 12

errors due to medication/ tech design factors

Answer 12

1. poor drug manufacturing/distribution practices (packaging, color)
2. complex or poorly designed technology

Question 13

staff/ human errors

Answer 13

1. knowledge deficit
2. inexperience
3. rushing
4. distracted/ interruptions
5. fatigue (man mode)
6. SOP violations
7. poor teamwork
8. failed communications

Question 14

errors due to system/workplace factors

Answer 14

1. lighting/ noise
2. disruptions
3. lack of safety culture
4. lack training/ supervision
5. inappropriate storage
6. understaffed

Question 15

how is swiss cheese model relevant

Answer 15

errors usually occurs as a result of a chain of events set in motion, leading to a chain effect, which is hard to detect

Question 16

latent errors or system failures

Answer 16

pose the greatest threat to safety in a complex system because they lead to operator errors.

• built into the system and present long before the active error
• difficult for people working in the system to see as they may be hidden in computers or layers of management

Question 17

Root cause analysis (3 question)

Answer 17

1. what happened (key steps)
2. what went wrong and why (identify failed processes)
3. what to do to prevent incident recurrence and suggest risk-reduction strategies

Question 18

steps to reduce errors

Answer 18

1. reduce reliance of (human) memory
2. simplify
3. standardise
4. use forcing and constraints functions
5. use protocols and checklist wisely
6. improve access to information
7. decrease reliance on vigilance
8. reduce handoffs
9. differentiate, eliminate look-alikes and sound alikes
10. automate carefully

Question 19

what are high-alert meds

Answer 19

drugs that bear a heightened risk of causing significant patient harm when used in error

• mistakes may or may not be more common
• but consequences of an error are more devastating

Question 20

Recommended guidelines for high-alert medications management

Answer 20

1. eliminate or reduce the possibility of error
   - remove high alert from clinical areas; limit available concentrationand volume
2. make errors visible
   - independent double checking for infusion pump settings to catch errors
3. minimise the consequences of errors
   - change practices to reduce the Adverse Effects of errors
   - close monitoring to improve early detection of errors

Question 21

advantages of CPOE

Answer 21

1. elimination of handwriting discrepancies
2. immediate error checking for dosage, frequency, ROA
3. drug interactions and allergy checking
4. serving DI databases
5. tool to document administration of medications by nursing
6. immediate transmission of orders to multiple disciplines
7. providing data to analyse drug utilisation and workflow
8. increase formulary adherence and compliance to prescribing guidelines
9. allowing price comparisons
10. intelligent prescribing

Question 22

ISMP recommendation

Answer 22

1. use generatic names
2. avoid including salt of chemicals
3. differentiate generic names from brand names
4. standardise inclusion of suffixes
5. standardise use of mnemonics or short names
6. standardise font (size, style and color)

Question 23

Closed Loop Medication Management system (CLMM)

Answer 23

1. enhanced medication safety process (ensure right patient, drug, dose, time)
2. efficiency of ward processes:
   - reduced turn around time for medication stock
   - reduced time required to administer medications to patients

Question 24

components of CLMM

Answer 24

1. Electronic Inpatient Medication Record system- eIMR
2. Clinical Decision Support System- CDSS
3. inpatient Pharmacy Automated System- iPAS
4. Electronic Medication Administration Record System- eMARS