Med Safety and Quality Improvement - Quiz 2 Flashcards
What is medication safety?
Freedom from preventable harm due to medication use
What is a medication error?
Any prevenetable event that may cause or lead to inappropriate meduse or patient harm
What is the difference between ADRs and med errors?
ADRs are usuly not preventable
What is a close call (near miss)?
An error corrected before reaching the patient
What is the difference between error of omission vs commission?
Ommision: left out
Commission: done incorrectly
What are causes of med errors?
- At-risk behavior
- Reckless behavior
What is the org dedicated to prevention of med errors? What programs did they initiate?
ISMP (Institute for Safe Med Practice)
MERP (Med Error Reporting Program) -> provides recmmendations for prevention
What is the organization that accredits and certifies a lot of HC org and programs in the US?
Joint commission
What is set annually by the JTC to assure accountability is safe med practices?
National Patient Safety Goals
What are examples of patient identifiers?
- Name, med record number, DOB
What is used to ensure safe use of anticoagulants?
- Dosing protocols
- Programmble pumps
What is used t maintian and communicate accurate patient medicaqtions?
Med reconciliation and discharage counselin
What are the components of fostering a culture of safety?
- Acknowledge high-risk behaviors
- Blame-free environment
- Collaboration across disciplines
- Resources
Describe the Swiss cheese model?
When holes in safety are alligned, it allows for hazard to reach the end of the process and eventually the patient
What strategies are consdered highly reliable for preventing med errors?
- Hard stops
- Automated processes
- Repetitive steps
What are solutions to communicate med info to patients with poor health literacy?
- Reading levels appropriate to patient
- Provide pictures
- Communicate in their language
- Utilize translation services
Differentiate MTR, MTM, and MAP
MTR: Medication therapy review
MTM: Medication therapy management (preparation of PMR)
MAP: Medication-related action plan
What are common examples of stewardship programs?
- Antimicrobials
- Anticoag
- Opioids
What is job of a CPA?
Perform advanced care activies and requirements differ based on legal jurisdication and institutions
What are the components of a response plan when a med error were to arise?
- Internal notification
- External notification
- Disclosure
- Investigatiobn
- Improvement
What entities are informed of med errors?
- P and T committees
- Medication Safety Committee
What is an example of prospective evaluation?
Failure mode and effects analysis (FMEA): proactive method used to reduce the frequency and consequences of errors
What is an example of retrospective evaluation?
Root cause analysis (RCA): looks at events that ahve occurred by reviewing the sequence of events that lead to errors
What is an example of continuous evaluation?
Continuous quality improvement (CQI)
How do you avoid LASA drugs?
Tall man letters
exampels of high alert meds
- Anesthetics
- Antiarrhythmics
- Anticoags
- Chemo
- Epideral
- Hypertonic saline
- Immunosuppressants
- Inotropics
- Insulins
- Mag sulftate
- Neuromuscular blockers
- Opioids
- Oral hypoglycemics
- Parenteral nutrion
- KCl and phosphates
- SWFI
How do you do about a drug recall
Remove recalled meds from stock and prevent dispensing
What is code blue?
Emergency medical care (cardiac or respiratory arrest)
What is used for direct entry of med orders?
CPOE
Types of ADC?
- PyxisOmnicell
- ScriptPro
- Accudose
What are the benefits of using ADCs?
Enhanced security of controls
What meds should not be in ADCs?
- U500 insulin
- Warfarin
- High dose narcotics
Can you put meds bac in ADCs?
No, should be placed in drawer indicated for “returned” meds
What are common types of HANI?
- UTI
- IV lines
- C diff
- Catheters
- Oneumonia
Who should have contact precautions?
MRSA, VRE, C diff patients
Who shold have droplet precautions?
B pertussis, flu, RSV
Airborne precautions are recommened or who?
- Tb, MMV
How do we minimize catheter blood infections?
- Skin antiseptics (chlorhexidine)
- ABX
- mopregnated central venous catether
API in ABX hand soaps?
Chlrohexidine (Hibiclens)
Procedure for optimal hand washing?
- Before entering and after patient contact
- Donning and after removing gloves
- Injections
- Coughing and sneezing
- Handling food and oral meds
- Visiably soiled
What do you use for C diff hand washing?
Non-alcohol based rubs
How long should you wash hands?
15 second lather
How full is too full for sharps containers?
3/4 fulls=
Examples of supervised sharps collection sites?
- Hospital
- Pharmacy
- Police or fire stations
