Med Safety and Quality Improvement Flashcards
What 2 organizations are involved in improving medication safety?
The Joint Commission (TJC)
Institute for Safe Medication Practices (ISMP)
Medication error definition
any PREVENTABLE event that may cause/lead to inappropriate medication use or pt harm while medication is in control of HCP, pt or consumer
Which is unavoidable:
Adverse drug reaction (ADR) or medication error?
ADR
Sentinel event definition
Occurrence involving death or serious physical or psychological injury or risk thereof
Error of omission vs error of commission difference
Omission - something was left out that was needed for safety
Commission - something was done incorrectly
Characteristics of ISMP’s Medication Errors Reporting Program (MERP)
Confidential, voluntary
Provides expert analysis of system causes
Provides recommendations for prevention
What is a prospective way to do evaluation and quality improvement?
Failure mode and effects analysis (FMEA)
Used to reduce frequency and consequence of errors
What is a retrospective way to do evaluation and quality improvement?
Root cause analysis (RCA)
Investigates an event that already occurred and reviews the sequence of events that led to the error
What is a continuous way to do evaluation and quality improvement?
Continuous quality improvement (CQI)
Also includes lean and six sigma which minimizes waste and reduces defects
Who sets national patient safety goals (NPSG)?
Joint commission
Ex: use at least 2 patient identifiers when providing care, treatment, and services
What are common ways to reduce med errors?
Avoid unsafe/confusing abbreviations Tall man lettering High-alert medications MTM Med reconciliation Indications and proper instructions on prescriptions Use metric system Don't identify meds based on packaging alone Avoid multiple dose vials
What are the 5 “rights” of medication administration
Right... Route Patient Medication Dose Time
What medication characteristics make a medication high alert?
Hightened risk of causing significant patient harm if used in error
What are some high-alert medications?
Anesthetics Antiarrhythmics Anticoagulants Chemotherapeutic Epidural/intrathecal meds Hypertonic saline Immunosuppressants Insulin Magnesium, potassium, phosphate injection Opioids
What should be written instead of “use as directed” on a prescription?
Use per instructions on the dosing calendar (warfarin) or packaging (Medrol dosepak), etc
