MEDICATION SAFETY Flashcards
What is a medication error?
Event that may cause or lead to inappropriate medication use of pt harm
What is an adverse drug event?
Harm resulting from medication or lack of medication (error may or may not have occurred)
- ex. Pt w/ depression overdoses on antidepressants
What is an adverse drug REACTION?
A type of adverse drug event that occurs at normal doses that results in an undesired, unintended, or unexpected reaction to a medication
EX. pt experiences hepatoxicity (liver damage) after taking methotrexate for rheumatoid arthritis
What is a near miss?
Event that could have resulted in harm but did not reach the pt as a result of chance or timely intervention
What are the medication use process?
Prescribing, transcribing, dispensing, administering, monitoring
What medication error can occur with prescribing?
- inadequate knowledge of drug interaction
- pt factors such as allergies, pregnancy, renal impairment not taken into account
- inappropriate drug, dose, route or administration time
What medication error can occur with transcribing?
Prescribed meds transcribed incorrectly or not transcribed at all
What medication errors can occur with dispensing?
- Incorrect medication, dose, route or quantity dispensed
- Dispensed meds labeled inappropriately
Administration errors:
- incorrect pt, medication dose, route or time
- administration omission
Monitoring errors:
- inadequate monitoring for effectiveness or side effects
- drug levels not ordered or followed up
What factors can contribute to medication errors?
- inadequate lighting
- messy work area
- distractions
- stress
- fatigue
What are high alert medications?
Medication which may result in an increased risk of pt harm if used inappropriately
EX. Insulin, opioids/narcotics, anticoagulants, chemotherapy, potassium chloride
What is CPOE?
Prescribers input orders directly into electronic medical system
- addresses illegible orders
- avoids transcription errors
- alerts prescriber to allergies, inappropriate doses/frequency/route/drug interactions
What is BCMA?
Nurse scans patients wristband, followed by medication to be administered
- confirms rights of meds
- can be linked with clinical decision support to alert nurse to important info such as allergies, vital signs, lab values
What are guardrails?
Limits specific to each medication programmed into IV medication pumps to ensure meds are administered safely
What is a soft minimum guardrail?
Minimum dose or rate for a given medication that can be administered (alert can be overridden by nurse after clinical check)
What is a soft maximum guardrail?
Maximum dose or rate for a given medication that can be administered (alert can be overridden by nurse after clinical check)
What is a hard maximum guardrail?
Maximum dose or rate for a given medication that can be administered (alert CANNOT be given, pump will not allow administration)
What is BPMH (best possible medication history)?
Process of obtaining a list of a pt prescribed an non prescribed meds using a systematic process of interviewing the pt/family and reviewing at least one additional reliable information source
- includes medication, dose, route and frequency
What is reconciliation?
Process of comparing medications orders on admission, transfer and discharge to previously ordered meds to ensure additions, changes and discontinuous are intentional and appropriate
- shared responsibility of physician and nurse
What is FMEA (failure mode and effect analysis)?
Systematic, proactive approach to evaluate a process to identify where and how it might fail and to access the relative impact of different failures in order to identify the parts of the process in greatest need of change.
- failure modes
- failure causes
- failure effects
