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c. pharm exam 3 (w13) > medical safety > Flashcards

medical safety Flashcards

1
Q

What was the function of QAs in the past?

A
  1. to collect incidet rates, discuss causes, finding blame. It was very “reactive”.
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2
Q
  1. Why is a QA form not part of the patient record?

2. how can an incident or QA form become admissable in court?

A
  1. Because it is internal data collection
  2. if nursing notes state what the QA should say (resident error, blade broke etc.), or if nursing notes refer to QA-it becomes admissable in court.
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3
Q

Human processes can be described along 2 dimensions; what are they?

A

Coupling and Interaction

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4
Q
  1. Interaction between element and process is either:

2. what is the difference between the two?

A
  1. complex or linear
  2. difference between linear and complex:
    - Complex=many alternative sub tasks(>alternatives>complexity)
    - Linear=set of fixed steps carried out in sequence
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5
Q
  1. what does “coupling” mean?
  2. what if the consequence is closely related?
  3. how does coupling make the interaction more complex?
A
  1. Coupling refers to the extent to which an action is related to its consequence
  2. The closer the consequence is related the “tighter” the coupling
  3. The tighter the coupling and more complex the interaction the greater
    the risk
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6
Q

according to Rasmussens’ System Model:

  1. what do we do to capacity when new technology arrives?
  2. how many impacting factors do we function within? what are they?
  3. how do these factors interact within a work situation?
A
  1. Systems operate at capacity. When there is new technology-we stretch it
  2. We function within 3 impacting factors
    a. Desire for safety/performance
    b. Workload
    c. Economics
  3. Pressures from each factor compete
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7
Q

what are 3 MAJOR ISSUES with medication error reporting and occurence?

A
  1. DEFINITIVE STUDIES of rates of anesthesia errors ARE LACKING, some studies estimate medication errors rate at approximately 1 in 130 anesthetics.
  2. PROBLEMS IN ACCURATE REPORTING suggest this could be an underestimation.
  3. the number of drugs administered during an anesthetic multiplied by the number of anesthetics a CRNA administers (add changes in personnel)=INCREASED NUMBERS= INCREASED COMPLEXITY
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8
Q

2003 ASA Closed Claims Study Medication errors in anesthesia
what was most frequent to least on list?
1-8

A 
2003 ASA Closed Claims Study Medication errors in anesthesia
(in descending order of frequency)
1. Succinylcholine
2. Inhaled agents
3. Opioids
4. Local anesthetic agents
5. Epinephrine
6. Cardiovascular agents
7. Antibiotics
8. NDMRs
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9
Q

2003 ASA Closed Claims Study

Common Anesthesia Related Incidents

A

2003 ASA Closed Claims Study
Common Anesthesia Related Incidents
1• Circuit Disconnect
2• Drug errors (dose or choice)
3• Failure to intubate, undetected esophageal intubation, premature extubation, aspiration
4• Failure of airway access devices, breathing systems, monitors or gas supply

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10
Q

a. what are 12 associated Factors which may cause errors?

b. what are these factoids based on?

A 
a. Associated Factors
1• Haste
2• Distraction
3• Fatigue/lack of vigilance
4• Carelessness
5• Failure to plan
6• Limited access to patient
7• Lack of skilled assistance
8• Inadequate supervision
9• Inexperience
10• Poor communication
11• Lack of familiarity with equipment
12• Failure to perform a pre-use equipment check
b. (Based on ASA closed claim study and Australian Incident Monitoring Study)
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11
Q
  1. what is the 100,000 Lives Campaign?

2. In what categories does it aim to reduce errors in?

A
  1. Initiated by the Institute for Healthcare Improvement
  2. Proposed to save lives by reducing errors:
    Aimed at;
    –Respirator pneumonia
    –IV catheter infections
    –Surgical site infections
    –Rapid response
    –MI care
    –Preventing medication errors
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12
Q
  1. what other institution is trying to help to prevent errors
  2. what practices have they implemented thus far?
A
  1. JCAHO
  2. Patient Safety Goals
    - -Patient Identification
    - -Communication among caregivers
    - -Safe medication use
    - -Infection prevention
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13
Q

what are things JCAHO is involved with in our profession?

A

JCAHO
Med practice in anesthesia
Labeling (what should it include?)
Securing medications (double lock for controlled drugs)

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14
Q

Measuring Quality: An Elusive Metric

what are some Examples of common quality indicators:

A

Examples of common quality indicators:

  • -Adverse events (dental-cardiac)
  • -N&V
  • -Re-intubation
  • -On-time case starts
  • -Adherence to protocols (SCIP)
  • -Pharmacy and staffing fiscal responsibility
  • -Documentation audits
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15
Q

Adverse Drug Events (ADE)

  1. what is the annual cost?
  2. why is there focused attention?
  3. what is occurence %?
  4. If an ADE occurs in > 65y/o: how likely to visit ER? how likely to be hospitalized?
  5. ~how many are preventable?
A

Adverse Drug Events (ADE)

  1. Estimated annual cost $150 billion
  2. Focus of attention due to impact and iatrogenic nature
  3. Occurs in an estimated 5-20% of patients
  4. Age >65 are 2.5 times more likely to have an ADE requiring ED visit and 8 times more likely to require hospitalization
  5. Approximately two thirds of ADE are thought to be preventable
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16
Q

Adverse Drug Events (ADE) One of 5 basic types

A

Adverse Drug Events (ADE)

  • Adverse drug reactions
  • Adverse drug withdrawal events
  • Therapeutic failures
  • Overdoses
  • Medication errors
17
Q

Adverse Drug Reactions (ADR)

ADR categorized how?

A

Adverse Drug Reactions (ADR)
1. ADR categorized as A or B;
A=Augmentation of drug effects
Primary- the result of the drugs primary effect (excessive bleeding after coumadin)
Secondary- the result of secondary effect (Parkinsonian effects from from metoclopramide)
B=Bizarre effects Idiosyncratic, allergic

18
Q

what are 3 causes of Adverse Drug Withdrawal Therapeutic Failure?

A

1-ADW- withdrawal symptoms after abrupt discontinuation (opiate withdrawal, rebound HTN after long term clonidine use)
2-When drug is not given or not optimally given
3-Therapeutic failure-often related to inadequate dose or decreased effect from concurrent therapy
-

19
Q

Overdoses

  1. classafication:
  2. causes:
  3. who is most at risk?
A

Overdoses

  1. Intentional or accidental
  2. causes:
    - –Doses are not those normally used
    - –In self administered can be knowledge deficit or improper prescribing (excluding suicide attempts)
    - –In anesthesia they are often the result of not adjusting to patients situations or unintentional:
  3. Most common in the very young or the very old
20
Q

Medication Errors:

  1. definition:
  2. causes of med errors:
  3. when caught prior, classified as a what…?
  4. what “checks” help prevent med errors?
A

Medication Errors

  1. Defined as “unintended acts of either commission or omission resulting in actual orpotential harm to a patient or does not achieve it’s intended outcome”
  2. causes:
    - –Commission-Mislabeled drugs, sound/look-a-likes, decimal point issues, miscalculations
    - –Omission-failure to treat, forgotten drug
  3. When caught prior are classified as “near misses”
  4. “5 rights”
21
Q

Managing Adverse Drug Events:

  1. first step in managing them?
  2. what does reporting incidents lead to?
  3. what does FDA medwatch do?
A

Managing Adverse Drug Events

  1. Recognize
  2. Reporting incident leads to recognition of a problem which leads to motivation to resolve
    - - Nonpunitive
    - - Identify triggers
  3. FDA Medwatch program
    - - Helps gather info on serious events “Dear Health Professional” letters Website and email notifications
22
Q

what is essential to improve drug administration safety?

A

Close analysis and review of processes is essential to insure and improve drug administration safety

23
Q

what cannot be forgotten when administering meds?

A

• Careful labeling, double-checking for the “rights” of drug administration and second nurse verification can’t be forgotten.

24
Q

The Solution: The Big Picture?

  1. what are improvements being made now to reduce med errors?
  2. what is the problem that still remains?
A

The Solution: The Big Picture?
1• Improvements in
–a•drug administration and preparation practices by pharmaceutical companies and pharmacy departments
–b• The reduction of look alike vials and sound alike drugs
–c• Simple improvement in labeling has reduced errors
2• One problem that remains refers back to the propensity to blame individuals

25
Q
  1. what would some say is the cause of incidents?
  2. why really are there medication failures?
  3. why are some small errors leading to the end error so hard to see?
A

1-Incident investigation often ends with the conclusion that human error is the cause of many incidents
2-In reality, complex systems fail because of a series of multiple failures, none of which are capable of causing the incident individually.
3-Such failures are easily missed and may change in pattern over time.

26
Q

The Solution: The Bigger Picture

what are safety experts calling for?

A

• Safety experts are calling for a change in the culture

27
Q

anesthesia drug safety:
In Las Vegas, oklahoma and Nebraska; a study concluded that ____?
That caused the AANA 2009 state this_____?

A
  • reuse of needles causing 60,000 exposures to hepatitis

- never reuse anything even on the same patient

28
Q

what meds did FDA look at regarding safety

A

Halothane, succ, droperidol

29
Q
  1. what is the FDA? what is it part of?
  2. what is the largest of the FDA centers?
  3. what is their mandate?
A
  1. food & drug administration. part of the dept of health and human services
  2. center for drug evaluation and research (CDER)
  3. –prompt and effecient review of drug research
    - -take action on marketing of human drugs
    - -ensure that human drugs are safe and effective
    - -monitor drugs for unexpected effects after hitting market
30
Q

opportunities for errors:

what checks do we do prior to surgery?

A

1• Verification of correct procedure
2• Informed consent
3• Presence of allergies
4• Assuring functional capacity of anesthesia equipment and the pre-anesthesia checklist

31
Q
  1. IOM reported how many deaths d/t medical errors in 1999?

2. what does their report say are common themes?

A
  1. 98,000 deaths in 1999 s/t med errors
  2. • Errors are inevitable when humans are involved
    • Many are predictable, most avoidable
    • Usually multifactoral
    • Errors are costly in terms of M&M, dollars, guilt, emotional
    suffering, professional embarrassment etc)
32
Q

what are the human limitations?

A 
Human Limitations
• Limited memory
• Distractibility
• Negatively impacted by stress
• Multitasking threshold
• Fatigue
• Alcohol and/or substance abuse

c. pharm exam 3 (w13) (6 decks)

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