Med Safety Flashcards
Define: Medication error
Any preventable event that leads to inappropriate medication use or patient harm
Define: Adverse drug reaction (ADR)
Usually NOT preventable, but more likely if medication given to higher risk pt
Define: Near miss
Error occurred, but was corrected before reaching patient
Define: Sentinel error
Patient safety event that results in death, severe harm (of any duration), or permanent harm (regardless of severity)
Define: Errors of omission
Occurs when something was left out that is needed for safety
Define: Errors of comission
Occurs when something was done incorrectly
What are the five rights with medication administration?
- Right patient
- Right time and frequency
- Right dose
- Right route
- Right drug
What are causes of medication errors?
-Low patient health literacy
-Insufficient training, lack of experience, or unfamiliarity w/ tasks
-Breakdowns in communication: hesistancy to speak up or question, rushed communication
-Competing priorities in face of stress, fatigue, or burnout: running on “autopilot”
-Fast-paced, high-volume environment w/ time constraints: frequent interruptions, laspes in concentration
-Complex technology and processes: creation of “workarounds” to subvert
What is the difference between at-risk behaviors and reckless behaviors?
At-risk behaviors: behavioral choice when individual lost the perception of risk or mistakenly believes risk to be insignificant or justified
Reckless behaviors: conscious disregard of substantial and unjustifiable risk
Organizations focused on Patient Safety:
1. The Institute for Safe Medication Practices (ISMP) is a __________(profit/nonprofit) organization dedicated to prevention of errors with. Part of the ISMP is the ____________, a confidential, voluntary reporting system. Medication errors and close cllas canbe reported on ____________.
- The Joint Commission (TJC) is an independent, __________(profit/nonprofit) organization that ____________. _________ is set annually by TJC with measures called “Elements of Performance”.
- Nonprofit; Medication Errors reporting Program (MERP); ISMP website (www.Ismp.org)
- Nonprofit; Accredits and certifies healthcare organizations and programs in the US; National Patient Safety Goals (NPSGs) - for hospitals
What are national patient safety goals?
-Use at least two patient identifiers (name, medical record number, and DOB; inappropriate identifiers: zi code, room number, physician name)
-Improve staff communication (report critical results of tests and diagnostic procedures on timely basis)
-Use medications safely (label al medicatoins and in perioperative and procedural settings, reduce likelihood of pt harm w/ anticoagulants, maintain and communicate accurate pt medication information)
-Reduce likelihood of patient harm w/ anticoagulants: dosing protocols (starting dose, alternate dosing, DDIs, dietary-food interactions, monitoring), programmable pumps, provide education for patients
-Maintain and communicate accurate medication information (medication reconciliatoin, conducting discharge counseling)
-Use clinical alarms safely
-Prevent infections (comply w/ CDC or WHO hand hygiene guidelines)
What are some accrediting organizations?
- Center for Medicaid and Medicare Services (CMS)
- National Association of Boards of Pharmacy (NABP)
- Accreditation Associatoin for Ambulatory Health Care (AAHC)
- Accreditation Commission for Health Care (ACHC)
- Center for Improvement in Healthcare Quantity (CIHQ)
- Utilization Review Accreditation Comission (URAC)
Methods to reducing error:
1. Most errors are made from multiple, smaller errors at different steps in the process called the “____________” model.
- To investigate errors, use a ________-based approach. After investigation of errors, implement mitigation strategies to prevent reoccurance.
- What are some high, medium, and low reliability human factors engineering strategies?
- “Swiss Cheese” Model
- System-based approach - identifies factors and situations likely to increase human error (blame-free environment)
- -High reliability: forcing functions (creates hard stops in design or process to eliminiate risk of incorrect use), computerized automation, human machine redundancy (creating a repetitive step to confirm a correct action)
-Medium reliability: standardization and simplification, environment and physical layout, reminders and alerts, double checks
-Low reliability: education and training, policy changes
Strategies to manage care transitions effectively
- Medication reconciliatoin (“med rec”)
-Make list of current medications including OTCs and dietary supplements
-Develop list to be prescribed
-Compare medications on two lists and decide to continue, stop, or hold medications based on comparison and clinical status of pt
-Communicate new list to pt, caregivers, and other HCPs in pt’s care - Perform patient counseling and provide written information at reading level appropriate for pt
-Make attempts to communicate to pt in their language using on-site staff or dial-in translational services
- Include indications and proper instructions on prescriptions
-Avoid directions of “as directed”
Methods to reducing medication errors:
1. Errors may be discovered during a medication therapy management review (MTR) as part of a medication therapy management (MTM) proces. Who are targets for pts with MTM?
- ________ team involves clinicians from different backgrounds to share expertise, resources, and skills to improve outcomes. A team may work together under a ____________ between a physician and pharmacist or less formal team (ex. rounding at a hospital). Stewardship is a team process of reviewing medication safety and efficacy often for _________, __________, and __________ drug classes.
- Pts w/ multiple chronic conditions and likely to incur annual costs for covered drugs that exceed a predetermined level –> reviews can identify missing therapy or de-prescribing, addressing non-adherence, or identifying cost saving methods
- Interdisciplinary; collaborative pratice agreement (CPA); antimicrobials, anticoagulants, and opioids
Methods to reducing medication error:
1. A medication error policy should include response, reporting, and evaluation and quality improvement. What are some considerations for response and reporting?
- In evaluation and quality imporvement, this should be prospective including FMEA, retrospective with RCA, and continuous with Lean and Six Sigma. Explain these elements.
- -Response: who to notify within and outside of institution, what information to disclose to pt/family, process for investigation of error, and process for preventative actions
-Reporting: all errors including near misses should be reported to prevent similar errors from being made, investigation should take place quickly (in hospitals: report to Pharmacy and Therapeutics = P&T committee and Medication Safety Committee)
- -FMEA: failure mode and effects analysis to reduce frequency and consequences of error
-RCA: root cause analysis to review the sequences of events that led to the error)
-Lean: focuses on minimizing waste
-Six Sigma: focuses on reducing defects with DMAIC: define, measure, analyze, improve, and control)
What is TJC’s minimum list of “Do Not Use” abbreviations? (FYI: ISMP provides more)
U or u –> mistaken for 0, 4, or cc –> write “unit”
IU –> mistaken for IV or 10 –> write “international unit”
QD, Q.D., q.d., qd OR QOD, Q.O.D., q.o.d –> mistaken for eachother, period after the Q mistaken as I and O mistaken for I –> write “daily” or “every other day”
Trailing zero or lack of leading zero –> decimal point is missed resulting in 10-fold dosing error –> write “X mg” or “0.X mg”
MS, MS04, and MgSO4 –> confused with morphione sulfate or magnesium sulfate –> write “morphine sulfate” or “magnesium sulfate”
What are High-Alert medications, and list examples?
High-Alert Medication: heightened risk of causing significant pt harm if used in error that often need policies, protocols, or order sets for use (ex. using premixed products, limiting concentrates)
ISMP’s High-Alert Medication List:
-Anesthetics, inhaled or IV (ex. propofol)
-Antiarrhythmics, IV (ex. amiodarone)
-Anticoagulants/anthithrombotics (ex. heparin, warfarin)
-Chemotherapeuics (ex.methotrexate)
-Epidural/intrathecal drugs
-Hypertonic saline
-Immunosuppressants (ex. cyclosporine)
-Inotropics (ex. digoxin)
-Insulins
-Magnesium sulfate injection
-Neuromuscular blocking agents (ex. vercronium)
-Opioids
-Oral hypoglycemics (ex. sulfonylureas)
-Parenteral nutrition
-Potassium chloride and phosphates for injection
-Sterile water for injection
Methods to reducing errors:
1. What is tall-man lettering used for?
- Healthcare organizations often have a policy to use the metric system where weight is expressed in _____ and volume expressed in _____.
- For emergency medications/crash carts, medications should be in ______ packaging and be _______-specific. During emergencies, __________ sheet should be available with references of weight-based dosing. During a code blue, _________ communication should be used.
- Look-alike, sound-alike drugs (ex. celeXA vs. celeBREX or predniSONE vs. prednisoLONE)
- kg; mL
- Unit-dose (contains single dose); age-specific; standardized drug reference sheet; closed-loop communication (repeating back information for verification)
Pharmacy Informatics: discuss the benefits of –> Computerized physician/provider order entry (CPOE)
Allows direct entry of medical order into computer system (reduces errors w/ handwriting; can incorporate clinical decision support = CDS; can include standard order sets, pathways, and protocols) –> caution w/ alert fatigue
Pharmacy Informatics: discuss the benefits of –> Barcoding
Ensures right medication going to right pt (used at bedside in hospitals, infusion pump, outpatient)
Pharmacy Informatics: discuss the benefits of –> Automated Dispensing Cabinets (ADCs)
Pyxis, Omnicell, ScriptPro, Accudose –> enhanced security of controlled drugs with recording detailed information about transactions
Pharmacy Informatics: discuss the benefits of –> Sterile Compounding Technology
Automated compounding devices, IV workflow management systems, IV robots –> interface with EHR to eliminate transcription errors from manual entry into one system to another
Pharmacy Informatics: discuss the benefits of –> Patient Controlled Analgesia (PCA) devices
Prevents pt from taking more medication than ordered, allows quick treatment, and allows administration of smaller doses to help reduce side effects
What are methods to improve automated dispensing cabinet (ADC) safety?
- TJC requires pharmacists review the order before medication can be removed by ADC except in special circumstances (overrides)
2, Patient’s MAR should be accessible while removing medications from ADC and use of barcodes to prevent wrong doses or drugs being administered to pt
- Look-alike, sound-alike medications should be stored in different locations within the ADC
- Certain medications should NOT be put in ADC (ex. U-500 insulin, warfarin, and high-dose narcotics)
- Nurses should NOT be permitted to put medications back into medication compartment (have separate drawer for all returned medications)
- If the machine is in a busy, noisy, or poor-lit environment, errors increase
What are some safety considerations and safety steps for patient controlled analgeisa (PCA) devices?
Safety considerations:
-Devices can be complex and require setup and programming –> only use by well-coordinated healthcare teams
-Pts should be cooperative and should have cognitive assessment prior to using PCA
-Friends and family should NOT administer PCA doses (TJC requirement)
-Caution in higher risk pts for respiratory depression (though rare w/ PCAs): elderly, obesity, concurrent use of CNS depressants
Safety Steps:
-Limit opioids available outside of PCA
-Educate staff about hydromorphone and morphine mix-ups
-Assess pt’s pain, sedation, and respiratory rate on a scheduled basis
Infection Control: What are the common types of hospital-acquired (nosocomial) infections?
-Urinary tract infections from indwelling catheters –> remove the catheter ASAP
-Bloodstream infections from IV lines (centrals lines have highest risk) and catheters
-Surgical site infections
-Clostridioides difficile
-Pneumonia (mostly due to ventilator use)
Infection Control: What are general contact, droplet, and airborne precautions, and when are they recommended?
-Contact precautions: recommended in pts colonized/infected w/ MRSA, VRE, and C. diff (single pt rooms, PPE)
-Droplet precautions: recommended in pts active B. pertussis, influenza virus, RSV, adenovirus, rhinovirus, N. meningitidis, and groupA streptococcus for first 24 hours of antimicrobial therapy (single pt rooms, masks)
-Airborne precautions: recommended in pts with active pulmonary TB, measles, or varicella virus (N95 or higher mask depending on disease, pt should be placed in airborne infection isolation room = AIIR)
Infection Control: What are good catheter measures to take?
Most important = aseptic technique during catheter insertion including proper handwashing and utilizations of SOPs
-Minimize use with IV–>PO conversions when possible
-Use fo skin aseptics (2% chlorhexadine), ABX impregnated central venous catheterics, and ABX/ethanol lock therapy if benefits outweight risks
Hand Hygiene:
1. Antimicrobial hand soaps that contain _________ may be preferable in healthcare facilities.
- When should handwashing be performed?
- Chlorhexidine
- -Before entering and after leaving pt rooms, between pt contacts if more than one pt in room
-Before donning and after removing gloves
-Before handling invasive devices including injections
-Before handling food and PO medications
-After coughing or sneezing
-Whenever hands are visibly soiled
Hand Hygiene:
1. When to use soap and water (NOT alcohol-based rubs)?
- Procedures for soap and water technique vs. alcohol-based hand tub technique
- -Before eating
-After using the restroom
-Anytime there is visible soil
-After caring for pt w/ diarrhea or known C. diff or spore-forming organisms (alcohol-based hand rubs have poor activity against spores)
-Before caring for pts w/ food allergies - -Soap and water technique: Wet both sides of hands, apply soap, and rub together for at least 15 seconds. Rinse thoroughly. Dry with paper towel and use the towel to turn off the water.
-Alcohol-based hand rub: Use enough gel (2-5mL or about the size of a quarter). Rub hands together until the gel dries (15-25 seconds). Hands should be completely dry before putting on gloves.
Safe Injection Practices
- Never administer an PO soluatoin/suspension intravenously. Use oral syringes (which are difficult or impossible to attach a needle for IV injection) and label syringse “for oral use only”
- Never reinsert used needles into a multiple-dose vial or solution container. Single dose-vials are preferred when medications administered to multiple pts.
- Needles used for withdrawing blood or other bodily fluids or used for administering medications or other fluids should ideally have engineered sharps protection to reduce exposure incidents
- Never touch tip or plunger of syringe to avoid contamination
- Lancing (“fingerstick”) devices should NOT be used in more than one pt. Glucometers should NOT be shared ideally. If sharing in institutional setting, clean and disinfect after each use.
- Disposable needles that are contaminated should never be removed from original syringes. Thow entire needle/syringe assembly in sharps container.
- Immediately discard used disposable needles or sharps into sharps containers without recapping
- Sharp containers should be easily accessibly and NOT allowed to overfill (should be routinely replaced when container about 3/4 full with line)
