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PR3145 > Medication Safety > Flashcards

Medication Safety Flashcards

1
Q

“Just Culture”

A
  • Foster open reporting, while holding people appropriately accountable for their actions
  • Culture of accountability
  • Each lvl of culpability has its own causes & solutions

5 behaviours:

1) Human error
2) At-risk behavior
3) Reckless
4) Knowledge
5) Purpose

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2
Q

Benefits of “Just Culture”

A
  • creates psychological safety for staff to report errors
  • common language to consistently & fairly evaluate human (staff) behaviours
  • shift focus to system design & behavioural choice
  • creates culture of accountability
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3
Q

Define “side effects”

A
  • Known effect related to pharmacological properties of a medication
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4
Q

Define “Adverse Drug Event”

A
  • An injury due to a medication
  • May be preventable/ not preventable

–> Costly & results in significant additional healthcare resource consumption

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5
Q

Define “Adverse Drug Reactions”

A
  • Noxious & unintended response to normal doses a medication

- Excludes injuries caused by error (eg. overdose)

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6
Q

Define “Medication error”

A
  • Preventable event
  • May cause or lead to inappropriate med use/pt harm

May result in:

  • Adverse event
  • Near miss
  • Neither harm nor potential for harm
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7
Q

Define “near miss”

A
  • Event/situation that could have resulted in medication error
  • Either by chance or through timely intervention
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8
Q

Steps in Med Use Process

A
  • Prescribing
  • Preparation & describing
  • Administration
  • Monitoring
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9
Q

How can errors occur in PRESCRIBING step

A
  • inadequate knowledge about drug indications & contraindications
  • not considering indv pt factors
  • wrong pt/route/dose/time/drug
  • inadequate communication
  • documentation
  • mathematical error when calc dose
  • incorrect data entry using computerised prescribing
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10
Q

How can errors occur in DISPENSING step

A
  • transcription error
  • failure to check for indv pt factors
  • labelling or packaging mix up
  • poor inventory control
  • documentation
  • mathematical error when calc dose or qtys
  • miscommunication
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11
Q

How can errors occur in ADMINISTRATION step

A
  • wrong drug/route/time/dose/pt
  • omission, failure to administer
  • inadequate documentation/communication
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12
Q

How can errors occur in MONITORING step

A
  • lack of monitoring of ADRs
  • drug not ceased if not working
  • drug ceased b/f course completion
  • drug levels not measured/followed up
  • communication failures
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13
Q

How can PATIENT FACTORS contribute to medication errors

A

1) Patients at higher risk of med error:
Eg. multiple meds/comorbidities/doctors/ specific condition (eg. renal impairment)/ cannot communicate well/ do not take active role in med use

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14
Q

How can MEDICATION/ TECHNOLOGY DESIGN FACTORS contribute to medication errors

A

1) Poor drug manufacturing/distribution practices
Eg. look-alike, sound alike (LASA), inappropriate packaging or design, distracting symbols or logo, misleading/confusing info, labels appear to be inaccurate/incomplete, looks too similar

2) Complex or poorly designed technology

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15
Q

How can STAFF/HUMAN FACTORS contribute to medication errors

A
  • Knowledge deficit
  • Inexperience
  • Rushing
  • Distracted
  • Fatigue, boredom, being on “automatic pilot”
  • violations to protocols/SOP
  • reluctance to use memory aids
  • poor teamwork/communication
  • -> confusion
  • -> using non-standard abbreviations
  • -> ambiguous/incomplete orders
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16
Q

How can SYSTEM/WORKPLACE FACTORS contribute to medication errors

A
  • frequent interruptions & distractions
  • absence of safety culture
  • inadequate training/supervision
  • inadequate staff numbers
  • inappropriate storage of medications
  • absence of readily available med & pt information
  • lack of automated dose checking alerts/functions
  • lack of workflow or protocol for use of HAM
17
Q

Why do errors occur in healthcare?

A
  • Most errors occur as a result of “a chain of events set in by faulty system design that induces errors or makes them difficult to detect”
  • latent unsafe conditions & active failures contribute to harm
  • harm results when layers of defence in a system fail to prevent a hazard from reaching a pt
  • human error
  • Latent error or system failures pose the greatest threat
  • -> failures built into the system
  • -> latent errors are hidden & ppl b/c accustomed to working around the problem
  • -> current responses focuses on active errors
  • -> if latent failures remain unaddressed, the accumulation makes the system more prone to future failure
  • -> discovering & fixing latent failures have a greater effect on building safer systems than efforts to minimise errors at the point at which they occur
  • Need an incident-reporting system to help an organisation’s ability to learn from error
18
Q

Root Cause Analysis (RCA)

A

A systematic approach to unds the causes of an adverse event & identifying system flaws, to prevent error from happening again

  • more effective way to improve quality & safety
  • focus on system causes
  • analyzing all factors contributing to the error
  • Usually conducted by 4-6 ppl, interprofessional

Steps:

1) Describe key steps
2) Identify failed processes
3) Suggest risk reduction strategies & their implementation

19
Q

[Steps to reduce errors]

Reducing reliance on human memory

A
  • use DDI checking systems
  • computerised data entry
  • bar-coding
  • computerised pt information
  • guided dose algorithms
20
Q

[Steps to reduce errors]

Simplify

A
  • limit choices of avail drugs in pharmacy
  • limit dosage strengths & conc for each drug
  • mix ivs
  • eliminate transcription of orders
  • automate dispensing on pt care unit
21
Q

[Steps to reduce errors]

Standardise

A
  • standardise prescribing conventions
  • protocols for complex med administration
  • standardise times of drug administration
  • store med in same place in every med room
  • standard equipment
22
Q

[Steps to reduce errors]

Using Forcing & Constraints Function

A
  • Effective error-proofing method that eliminates reliance on memory, checklists & double-check systems
  • -> special luer-lock syringes & indwelling lines
  • -> High-alert medications
23
Q

High Alert Medications

A
  • Drugs that bear a heightened risk of causing significant pt harm when used in error
  • Consequences clearly more devastating

Require special safeguards:

  • improve access to info about these drugs
  • limit access to high-alert meds
  • auxiliary labels & automated alerts
  • standardize ordering, storage, preparation & administration
  • employ automated or independent doublechecks
24
Q

Guide for managing High Alert Medications

A

1) Eliminate or reduce the possibility of error
- remove from clinical areas
- reducing no. of HAM stocked
- limiting avail conc & volumes

2) Make errors viable
- independent double-checking

3) Minimise consequences of errors
- change practices to reduce adverse effects of error that do occur
- close monitoring to improve early detection of errors

25
Q

[Steps to reduce errors]

Use protocols & checklists wisely

A
  • protocols support standardisation
  • checklist serve as reminders of critical tasks
  • reduce indv variation in practice
  • avoid statements that contain negatives
26
Q

[Steps to reduce errors]

Improve access to information

A
  • lack of info is a common cause of errors
  • have pharmacist avail on nursing units & at rounds
  • computerised order entry systems
  • computerised lab system
  • place lab reports & med records at bedside
  • colour-coded wristbands for pts w allergies
  • track errors or near misses & provide regular feedback
27
Q

[Steps to reduce errors]

Decrease reliance on vigilance

A
  • limits to the human attention span
  • double check system
  • automatic drug dose checking in high-risk situations
  • electronic monitors that raise alert when parameters are exceeded
  • rotate staff when performing repetitive functions
28
Q

[Steps to reduce errors]

Reduce handoffs

A
  • many errors occur during trf of materials, info, people, instructions or supplies
  • provide ready-to-administer products
  • reduce transcription of med orders
  • unit-dose systems
  • automated drug dispensing/filling systems
  • computerised prescriber order entry
29
Q

[Steps to reduce errors]

Differentiate: Eliminate look-alikes & sound-alikes

A
  • store in separate places
  • repackage or re-label
  • alert staff n post info
  • avoid stocking look-alike packages
  • striking caution stickers
30
Q

[Steps to reduce errors]

Automate carefully

A
  • can multiply error if error was made in generating inputs
  • hazardous when it leads staff to feel less responsibility for the task
  • -> bar-code technology to identify drugs
  • -> computerised order entry systems
  • -> train staff to double check the automation regularly
31
Q

CLMM

A

Efficiency of ward process:

  • Reduces turnaround time for med stock
  • Reduces time required to administer meds to pts

Components:

  • eIMR
  • CDSS
  • iPAS
  • eMARS

PR3145 (10 decks)

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