Medication Safety

Question 1

Medication Error

Answer 1

Any PREVENTABLE event that may cause or lead to inappropriate medication use or harm

Question 2

Adverse Drug Events

Answer 2

Are NOT avoidable!!
**different from a medication error!

Question 3

Sentinel Event

Answer 3

unexpected of occurrence involving DEATH or serious physicla injury

Question 4

At risk behaviors

Answer 4

-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

Question 5

Error of Commission

Answer 5

Something was done ICORRECTLY

Ex: prescribing bupropion to a patient with a history of seizures

Question 6

Quality Improvement Methods

Answer 6

-Failure Mode and Effects Analysis (FMEA)
-Root Cause Analysis (RCA)
-Continuous Quality Improvement (CQI)

Question 7

What is a prospective/proactive method of quality improvement to help reduce the frequency of errors?

Answer 7

Failure Mode and Effects Analysis (FMEA)

Question 8

What quality improvement method retrospectively investigates an event to study how a sequence of events led to an error?

Answer 8

Root Cause Analysis

Question 9

Do NOT use abbreviations

Answer 9

U (units)
QOD (every other day)
QD (daily)
Trailing zeros
MS

Question 10

High alert medications

Answer 10

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

Question 11

Precaution for high-risk insulin products

Answer 11

*do NOT place insulin in automated dispensing cabinets
*do NOT use “U” for units
*specify conditions for U-500

Question 12

Precautions for KCl

Answer 12

*remove all KCl vials from floor stock
*use premix containers
*use protocols
*label them “potassium added”

Question 13

Barcodes

Answer 13

*help identify right drug and right patient
*on infusion pumps and can prevent errors

Question 14

CPOE

Answer 14

Computerized Prescriber Order Entry
- helpful for errors in handwriting

Question 15

Automatic Dispensing Cabinets (ADC) - the most common error

Answer 15

Giving the wrong DRUG or DOSE to a patient
=== USE THE BARCODES

Question 16

What medications should NOT be placed in ADCs?

Answer 16

Warfarin
Insulin
High-dose narcotics

Question 17

PCA safety

Answer 17

• family and friends should NOT administer PCA doses (TJC requirement!)
  -limit the opioids
  -barcode technology
  -monitor pain, sedation, and respiratory depression

Question 18

5 rights

Answer 18

Right patient (2 identifiers)
Right drug
Right dose
Right route
Right time

Question 19

When should airborne procaution take place?

Answer 19

Tuberculosis
Meales
Varicella (Chickenpox)

Question 20

What helps reduce the spread of nosocomial infections?

Answer 20

HAND HYGEINE
- alcohol base is more effective than plain soap
EXCEPT:
-before eating
-after bathroom
-caring for c-diff
-before food allergy patient