Medication error

Question 1

Harm done to aptietns by preventable errors

Answer 1

3-16% patients

Question 2

types medication errors

Answer 2

prescribing
Dispensing
Administration
Wrong patient, drug, dose (calculations), route, DDI, contraindicated drug
Inadequate monitoring - warnings, communication

Question 3

Policies to prevent errors

Answer 3

Appropriate policies
Check patient identity and drug/solutions
Education, training, professional develoment - undergrad, postgrad
Info sources
Clear writing
Electronic precribing and warnings, patient record electronic
Involvement of patients and carers

Question 4

Routine preention of medical error

Answer 4

Medication reviews
Clinical pharmacy
Well designed clinical governance arrangements - reports, audit
Original pack dispensing
Control availability of high risk drugs
Adequate resources and staffing
Good drug and allergy history with appropriate documentation and warnings

Question 5

Removing hazard

Answer 5

Eliminate high risk items or procedures
Limit use or access eg IV vincristine paeds wrong route
Control storage

Question 6

Preventing hazardous action

Answer 6

Failsafe devices - infusion pumps wont deliver outside defined rate
Lock and key design - oral syringes cant be connected to IC
non luer spiral connecters
Information technology - wlwctronic systems preventing allergy drug prescribing

Question 7

What should be on all childrens percriptions

Answer 7

Age, weight, intended dose in mg/kg

Question 8

Minimising consequences of error

Answer 8

Availability of extravasation kits and staff trained
Automatic co-prescribing of antibdotes with hazardous drugs eg naloxone w IV opiates
Availability of flumazenil in all locations where midazolam used

Question 9

What antidote to midazolam shld be available

Answer 9

Flumazenil

Question 10

What point in care are errors often made

Answer 10

Transfer of care between interfaces eg primary and secondary - educate, provide lota of info etc

Question 11

What drug groups have special precautions for reducing errors

Answer 11

Anticoagulants - monitor, team
Chemotherapy - MDT, standardised, national
Infusion - standardised, support and training around them
Methotrexate - dose regimes, folate
Opiates - range use limited, carefully monitor if injectabel
Potassium - restricted conc K+ solutiona in hospitals

Question 12

Reporting systems

Answer 12

DATEX
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