Medication Errors 2 Flashcards
Step process for medication errors
- Reporting Harm Incidents
- Learn from Others
- Implement
CMIRPS
- What is it?
Canadian Medication Incident Reporting and Prevention System
- Collects medication error information across Canada
- Analyzes data
- Safety signals to inform of high alert errors
CMIRPS
- Health Canada
Primary funder of CMIRPS
- Can also use information obtained to create regulatory changes
CMIRPS
- CIHI
Canadian Institute for Health Information
- National System for Incident Reporting
Collects information from public facilities across Canada
CMIRPS
- ISMP
Institute for Safe Medication Practice
- Collections information from healthcare practitioners, community pharmacists, and patients
CMIRPS
- CPSI
Canadian Patient Safety Institute
- Global Patient Safety Alerts
Consumers report information here which is sent to ISMP Canada
CMIRPS - Reporting
- Where can the public report
safemedicationuse.ca
CMIRPS - Reporting
- Where can practitioners report (community pharmacies)
Community Pharmacy Incident Reporting (ISMP)
Pharmapod
CMIRPS - Reporting
- Where can healthcare facilities report
National System for Incident Reporting (CIHI)
Most common medication error
Insulin
Acetaminophen is also very common
Synthroid and Methadone also common
Most severe medication error
Hydromorphone (Sounds very similar to morphine)
What causes harms
Health Care Professional
Patient
Work Environment
Medicaitons
Tasks
Information Management System
Shared Care of Patients
What is causing these harms to occur
- Health Care Professionals
Training
Knowledge
Overwork
Poor Communication
What is causing these harms to occur
- Patients
Characteristics
Complexity of Condition
Cultural Sensitivities
Language Barriers
What is causing these harms to occur
- Work Environment
High Workload
Distractions
Lack of Standard Protocols
What is causing these harms to occur
- Medications
Naming of Medications
Labelling and Packaging
What is causing these harms to occur
- Tasks
Repetition
Patient Monitoring
What is causing these harms to occur
- Information Management Systems
Processes for first prescriptions
Accuracy of information
Not designed to reduce errors
What is causing these harms to occur
- Share care of patients
Limited communication between care providers
High Risk Medications
- Definition
Medications that are known to have higher risks of causing significant harm through errors
- Knowing these medications can help us mitigate risks
High-Alert Medications - Opioids
- Protocols
Having specific opioids used for specific cases and dosing guidelines
Dosing guidelines for: Opioid-naive, Opioid-tolerant, High-risk
Conditions that require dose adjustments
High-Alert Medications - Opioids
- Patient Assessment
Facility uses a standardized sedation scale to guide assessment and detection of sedation during opioid therapy
High-Alert Medications - Opioids
- Dispensing
Only a commercially manufacturer infusions or a central pharmacy prepared infusions are used
Which step in the prescription process do errors most occur
- Prescription Verification
- Product Checking
- Pick-Up
Implement Strategies
- Examples
- Forcing / Constrains
- Automation / Computerization
- Protocols / Standard Order Forms
- Independent Double Checking
- Rules / Policies
- Education / Training
Implement Strategies
- Forcing / Constraints
Most effective prevention strategy
- Makes it impossible to create an error
Implement Strategies
- Automation / Computerization
Decrease reliance on human memory
- Less effective than constraints as it is possible to override computer
Implement Strategies
- Protocols / Standard Order Form
Removes communication and transcription error
- Set process for specific situation
- Can be difficult to implement in community (multiple prescribers)
Implement Strategies
- Independent Double Checking
Two people involved
- Unlikely two people make the same mistake
- Still prone to error and bias
Implement Strategies
- Rules / Policies
Defines best practices
- Issue is it does not have to be followed and can be worked around
Implement Strategies
- Education / Training
Weakest tool
- Relies on humans to complete and absorb
- Is always needed however
Hierarchy of Effectiveness
- Low Levearge
Training / Education
Rules / Policies
Hierarchy of Effectiveness
- Medium Leverage
Standardization
Reminders, Double Checks
Hierarchy of Effectiveness
- High Leverage
Forcing Constrains
Automation or Computerization
