Med Safety & Quality Improvement Flashcards
What are two organizations that are actively involved in improving medication safety
Joint commission
Institute for Safe Medication Practices
Define medication safety
being safe from preventable harm related to medication use
Define medication error
Developed definition by the national coordinating council for medication error reporting and prevention (NCC MERP)
“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
ex: Errors made when prescribing/misreading handwriting, order communication, product labeling/packaging, compounding, dispensing, administration, education, or monitoring.
Adverse drug reactions
USUALLY UNAVOIDABLE effect of using the drug properly. these are more likely to occur when given to patients at higher risk for certain complications
ex: cough on lisinopril
What is a sentinel event? and what is the right response to the event
An UNEXPECTED EVENT involving death or serious physical or psychological injury of the patient
Find out what went wrong and implement systemic measures to try to prevent it from happening again.
Define just culture
Usually it’s not the healthcare worker that is the cause of the error, it’s the design of the medical system itself. So we should avoid placing the blame on individuals and instead create an environment where workers feel more comfortable disclosing errors because errors will always happen but we want to prevent the errors from reaching the patient.
What are some at-risk behaviors that are communication related and could lead to compromising patient safety
Not addressing questions/concerns
Rushed communication
What are some at-risk behaviors that are technology related and could lead to compromising patient safety
Overiding computer alerts without proper consideration
Not using available technology
What are some at-risk behaviors that are drug and patient related and could lead to compromising patient safety
Failing to check/reconcile their home medications and doses
Dispensing medications without complete drug knowledge
Not questioning unusual doses
Not checking/verifying allergies
What are some at-risk behaviors that are work environment related and could lead to compromising patient safety
Trying to do multiple things vs. focusing on a single complex task
Inadequate supervision and orientation/training
What are components of the plan that institutions should have in place to respond to medication errors
Internal notification (IMMEDIATELY report the error and document it)
External reporting
Disclosure
Investigation
Improvement
What are errors of omission and commission
Error of omission is when something that was needed for safety is LEFT OUT. Ex: not using a double check system for chemotherapy orders
“somebody left something out”
Error of commission is when something was done INCORRECTLY ex: prescribing bupropion to a patient with a history of seizures
“somebody did something wrong”
Who reports med errors and then what is the sequence of reports after that?
(the staff member who discovers the error the pharmacist usually and then there is a chain of command of who to report to.
Each state board of pharmacy has it’s own policy about reporting errors. (reporting within 48 hours but this time frame is state specific)
ex: community pharmacy reports to their corporate office, hospitals report via a medication event reporting system (MERS) and then they would also need to report to the Medication safety committee (if they have one, and then they report to the P&T), and their P&T committee (pharmacy and therapeutics)
The errors are reported to the Joint commission and every three years they are evaluated
When should we tell the patient about a medication error and how should we do it.
pharmacist is typically the one to report it if the medication error ended up in the hands of the patient or they consumed it.
We need to immediately report and
explain the circumstances leading to the error completely and honestly
Explain the nature of the error, the effects the error may have and how they can actively prevent errors in the future.
When do we need to tell physicians about medication errors
We should tell the physician when the error will lead to a
SE, ADR (like it may enhance their chance of getting it), or an effect on the disease being treated
