Medication Safety Flashcards
Medication Error
Any PREVENTABLE event that may cause or lead to inappropriate medication use or harm
Adverse Drug Events
Are NOT avoidable!!
**different from a medication error!
Sentinel Event
unexpected of occurrence involving DEATH or serious physicla injury
At risk behaviors
-Failure to check home meds
-not questioning unusual doses
- not checking allergies
-not addressing concerns
-rushed communication
-overriding computer alerts
-not using technology
- multitasking
-inadequate supervision
Error of Commission
Something was done ICORRECTLY
Ex: prescribing bupropion to a patient with a history of seizures
Quality Improvement Methods
-Failure Mode and Effects Analysis (FMEA)
-Root Cause Analysis (RCA)
-Continuous Quality Improvement (CQI)
What is a prospective/proactive method of quality improvement to help reduce the frequency of errors?
Failure Mode and Effects Analysis (FMEA)
What quality improvement method retrospectively investigates an event to study how a sequence of events led to an error?
Root Cause Analysis
Do NOT use abbreviations
U (units)
QOD (every other day)
QD (daily)
Trailing zeros
MS
High alert medications
ANticoagulants
Antiarrthythmics
Anesthetics
Chemo
Epidural/Intrathecal
Hypertonic saline
Immunosuppressants
Insulin
Inotropics (Digoxin)
Magnesium sulfate
Neuromuscular blocking agents (vecuronium)
Opioids
Hypoglycemics (Sulfonylureas)
Parenteral nutrition
KCl
Sterile water for injection
Precaution for high-risk insulin products
*do NOT place insulin in automated dispensing cabinets
*do NOT use “U” for units
*specify conditions for U-500
Precautions for KCl
*remove all KCl vials from floor stock
*use premix containers
*use protocols
*label them “potassium added”
Barcodes
*help identify right drug and right patient
*on infusion pumps and can prevent errors
CPOE
Computerized Prescriber Order Entry
- helpful for errors in handwriting
Automatic Dispensing Cabinets (ADC) - the most common error
Giving the wrong DRUG or DOSE to a patient
=== USE THE BARCODES
What medications should NOT be placed in ADCs?
Warfarin
Insulin
High-dose narcotics
PCA safety
- family and friends should NOT administer PCA doses (TJC requirement!)
-limit the opioids
-barcode technology
-monitor pain, sedation, and respiratory depression
5 rights
Right patient (2 identifiers)
Right drug
Right dose
Right route
Right time
When should airborne procaution take place?
Tuberculosis
Meales
Varicella (Chickenpox)
What helps reduce the spread of nosocomial infections?
HAND HYGEINE
- alcohol base is more effective than plain soap
EXCEPT:
-before eating
-after bathroom
-caring for c-diff
-before food allergy patient
