Medication Safety Flashcards
“Just Culture”
- 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
Benefits of “Just Culture”
- 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
Define “side effects”
- Known effect related to pharmacological properties of a medication
Define “Adverse Drug Event”
- An injury due to a medication
- May be preventable/ not preventable
–> Costly & results in significant additional healthcare resource consumption
Define “Adverse Drug Reactions”
- Noxious & unintended response to normal doses a medication
- Excludes injuries caused by error (eg. overdose)
Define “Medication error”
- 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
Define “near miss”
- Event/situation that could have resulted in medication error
- Either by chance or through timely intervention
Steps in Med Use Process
- Prescribing
- Preparation & describing
- Administration
- Monitoring
How can errors occur in PRESCRIBING step
- 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
How can errors occur in DISPENSING step
- 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
How can errors occur in ADMINISTRATION step
- wrong drug/route/time/dose/pt
- omission, failure to administer
- inadequate documentation/communication
How can errors occur in MONITORING step
- 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
How can PATIENT FACTORS contribute to medication errors
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
How can MEDICATION/ TECHNOLOGY DESIGN FACTORS contribute to medication errors
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
How can STAFF/HUMAN FACTORS contribute to medication errors
- 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
How can SYSTEM/WORKPLACE FACTORS contribute to medication errors
- 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
Why do errors occur in healthcare?
- 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
Root Cause Analysis (RCA)
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
[Steps to reduce errors]
Reducing reliance on human memory
- use DDI checking systems
- computerised data entry
- bar-coding
- computerised pt information
- guided dose algorithms
[Steps to reduce errors]
Simplify
- 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
[Steps to reduce errors]
Standardise
- standardise prescribing conventions
- protocols for complex med administration
- standardise times of drug administration
- store med in same place in every med room
- standard equipment
[Steps to reduce errors]
Using Forcing & Constraints Function
- Effective error-proofing method that eliminates reliance on memory, checklists & double-check systems
- -> special luer-lock syringes & indwelling lines
- -> High-alert medications
High Alert Medications
- 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
Guide for managing High Alert Medications
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
