Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PR3145 Finals > Medication Safety > Flashcards

Medication Safety Flashcards

1
Q

What is just culture?

A
  • just culture seeks to create a system of workplace justice that fostered open reporting, while simultaneously, holding people appropriately accountable for their actions
  • creates accountability; not punitive, nor blame free
  • human error -> accept
  • at risk behaviour -> coach
  • reckless, knowingly cause harm, purposely cause harm -> sanction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the benefits of just culture?

A
  • creates psychological safety for staff to report errors

- shifts focus from errors and outcomes to system design

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Define side effect?

A

A known effect, other than that primarily intended, relating to the pharmacological properties of a drug.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Define adverse drug reaction?

A

Any response to a drug that is noxious and unintended.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Define medication error?

A

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Define adverse drug event?

A

An injury due to medication.

May be preventable (medication error) or not preventable (adverse drug reaction or side effect).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Define near miss?

A

An event or situation that could have resulted in medication error, but did not.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the four main steps in the medication use process?

A
  1. Prescribing (choose correct med for given clinical situation, considering pt specific factors eg allergies & document)
  2. Preparation and dispensing (review and confirm prescription, prepare medicines, document and dispense with counselling)
  3. Administration (give right drug to right patient in right dose via right route at right time & document)
  4. Monitoring (monitor therapeutic effects and adverse drug reactions & document)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What errors can occur in prescribing?

A
  • inadequate knowledge about drug indications and contraindications
  • not considering indiv patient factors eg allergies
  • inadequate communication
  • poor documentation eg illegible
  • mathematical error when calculating dose
  • incorrect data entry using computerized entry
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What errors can occur during dispensing?

A
  • transcription error
  • failure to check for indiv pt factors eg allergies
  • labelling or packaging mixed up
  • poor inventory control
  • poor documentation eg illegible
  • mathematical error when calculating dosage or quantities
  • miscommunication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What errors can occur during administration?

A
  • wrong drug, route, time, dose, patient
  • omission - failure to administer
  • inadequate documentation or communication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What errors can occur during monitoring?

A
  • lack of monitoring for ADRs
  • drug not ceased if not working or course completed
  • drug ceased before course is completed
  • drug levels not measured or not followed up
  • communication failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the factors that can contribute to medication errors?

A

1) Patient factors
2) Medication/technology design factors
3) Staff/human factors
4) System/workplace factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the patient factors?

A
  • multiple meds or conditions
  • > 1 doctor
  • renal impairment, pregnancy etc
  • cannot communicate well
  • do not take active role in own medication use
  • children and babies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are medication/technology design factors?

A
  • inappropriate packaging or design causing confusion
  • look alike, sound alike
  • label inaccurate or incomplete
  • info is misleading or confusing
  • distracting logo
  • complex or poorly designed technology eg malfunction, wrong device selected
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the staff or human factors?

A
  • knowledge deficit
  • inexperience
  • rushing
  • distracted
  • interruptions
  • fatigue
  • poor teamwork
  • failed communication eg poor handwriting, missing zeros, incorrect units, non-standard abbreviations, ambiguous orders
17
Q

What are system/workplace factors?

A
  • lighting, noise level
  • frequent interruptions and distractions
  • absence of safety culture
  • inadequate staff numbers
  • breakdown of computers
18
Q

What are some practices which have been shown to reduce errors?

A
  • discover and fix latent failures

- report errors and near misses -> identify and eliminate latent errors via root cause analysis

19
Q

What is root cause analysis?

A

A systematic approach to understand the causes of an adverse event and identify system flaws (latent errors) that can be corrected to prevent the error from occurring again.
More effective than blaming the individual who made the mistake.
“Systems approach to error”

20
Q

What are 10 strategies to reduce errors?

A

1) reduce reliance on human memory
- drug interaction checkers
- computerized order entry
- use bar coding
- computerized pt info
- guided dose algorithms

2) Simplify
- limit drugs in pharmacy
- limit dosage strengths and conc for each drug
- eliminate transcription of orders
- automate dispensing on patient care unit

3) Standardise
- standardise prescribing conventions eg using generic names and no error prone abbreviations
- standardise time of administration
- store meds in same place
- use standard equipment

4) Use forcing and constraints function
- special syringes
- computerized order entry w dosage range checks
- special safeguards for high alert medications

5) Use protocols and checklists wisely
- reduce individual variation in practice
- but dont follow blindly
- make sure everyone agreed on the protocol or checklist and is aware that it is in use
- revisit regularly to evaluate and update

6) Improve access to information
7) Decrease reliance on vigilance (limit to attention span) –> double check, automatic checkers, rotate staff etc
8) Reduce handoffs
9) Differentiate - eliminate look alike sound alike (store in diff places)
10) Automate carefully

21
Q

How to prevent errors for high alert medications?

A
  • improve access to info abt these drugs
  • limit access
  • use auxiliary labels or automated alerts
  • standardize ordering, storage, preparation and administration
  • employ automated or independent doublechecks when necessary
  • reducing number stocked and limit avail conc and volumes
  • close monitoring to have early detection of errors
22
Q

What are the three steps for simplified RCA?

A
  • What happened? Describe key steps
  • What went wrong and why? Identify the failed processes.
  • What to do to prevent incident recurrences? Suggest risk reduction strategies and implementation.

PR3145 Finals (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions