Medication Errors

Question 1

Keys to preventing errors (4 things)

Answer 1

i. Reporting of errors
ii. Reporting of potential errors
iii. Nonpunitive approach to error reporting or “Just Culture”
iv. QSEN initiatives

Question 2

Adverse drug events includes

Answer 2

Medication errors

Question 3

Subclasses of adverse drug events

Answer 3

Adverse drug responses (ADR)

Question 4

ADRs include:

Answer 4

1. Allergic reaction (often predictable)

2. Idiosyncratic reaction (usually unpredictable)

Question 5

Drugs commonly involved in severe medication errors

Answer 5

CNS drugs
Anticoagulants
Chemotherapeutic

Question 6

“High-alert” drugs

Answer 6

2 nurses need to perform medication

Question 7

Event or situation that did not produce patient injury, but only because of chance no injury

Answer 7

near miss

Question 8

An event or situation or error that took place but was identified and captured prior to reaching the patient

Answer 8

Close call

Question 9

Strategies to Minimize errors (5 things)

Answer 9

a. Awareness (“speak-up”)
b. Computerized prescriber order entry (CPOE)
c. Bar codes and scanning devices
d. Automated dispensing machines

Question 10

Types of med errors

Answer 10

1. No error, although circumstances or events occurred that could have led to an error (close call)
2. Medication error that causes no harm (near miss)
3. Medication error that causes harm
4. Medication error that results in death

Question 11

Minimize verbal or telephone orders

Answer 11

i. Repeat order to prescriber
ii. Spell drug name aloud
iii. Speak slowly and clearly
iv. List indication next to each order

Question 12

Reporting med error, factual documentation only & what needs to be included:

Answer 12

i. Medication administered
ii. Actual dose
iii. Observed changes in patient condition
iv. Prescriber notified and follow-up orders

Question 13

Collection of the pt’s medication info with the focus on meds currently used (including Rx, OTC, supplements)

Answer 13

Verification

Question 14

Professional review of info to ensure that med/dosages are appropriate for pt

Answer 14

Clarification

Question 15

Further investigation of any discrepancies & changes in medication orders (discharged)

Answer 15

Reconciliation

Question 16

Reconciliation should be done at each stage of health care delivery: (4 things)

Answer 16

1. Admission
2. Status change (e.g., from critical to stable)
3. Patient transfer within or between facilities or provider teams
4. Discharge (the latest medication list should be provided to the patient to take to his or her next health care provider)