Medication Safety Flashcards
Medication error:
is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.
-“ This can include errors made in prescribing, order communication, product labeling, and packaging, compounding, dispensing, administration, education or monitoring”.
Medication error are:
- Preventable
Adverse Drug Reactions (ADRs) are:
- Not preventable
- Usually not avoidable
At Risk Behaviors that can compromise patient safety:
Drug and patient-related:
- failure to check/reconcile home medications and doses
- dispensing medications without complete drug knowledge
- Not questioning unusual doses
- Not checking/verifying allergies
Communication:
- not addressing questions/concerns
- rushed communication
Technology:
- overriding computer alerts without proper consideration
not using available technology
Work environment:
- trying to do multiple things vs. focusing on a single complex task
- inadequate supervision and orientation/training
Community Pharmacy:
Use a second patient identifier.
Ask for the patients address or date of birth in addition to the patients name.
Open the bag.
Employ technology. Flag patients with similar names.
Educate patients.
Sentinel event:
is an unexpected occurrence involving death or serious physical injury of a patient.
Errors of Omission- “OMI” like omitted
Something was left out that is needed for safety.
ex. failing to use a pharmacist double check system for chemotherapy orders.
Error of Commission- “Commi” like committed a crime
Something was done incorrectly.
ex. prescribing bupropion to a patient with a history of seizures.
System Based Causes:
- Focus on the system, not the individual. [Instead of placing blame on the individuals, healthcare professionals should find ways to improve the system (“just culture”)]
- Errors will always occur, but the goal is to design systems to prevent medication errors from reaching the patient.
In a just culture, safety is valued, reporting of safety risks is encouraged without penalization, and a clear and transparent process evaluates the errors.
automated dispensing cabinet
- used to reduce medication errors
- reduce pharmacy workload
Response:
A medication error occurred. What should be done?
Take care of the patient.
Immediately report the error.
Document the error.
External notification
Investigation: RCA (Root Cause Analysis)
Improvement
[Telling the patient]
The patient should be told about the error.
- the pharmacist is typically the one to report a medication error
- circumstances leading to the error should be explained completely and honestly
- patient should understand the nature of the error, what effects the error may have, how he or she actively prevent errors in the future.
——————————————————————————————————————–[Telling the physician]
- the physician must be contacted if the error will lead to a side effect.
- the prescriber must be notified if the error will cause an adverse drug reaction.
- the physician must be told if the error will impact the disease being treated.
Response:
Institutions should have a plan in place for responding to medication errors. The plan should address the following:
1)
2)
3)
4)
5)
1) Internal notification
- who should be notified within the institution and within what time frame?
2) External notification
- who should be notified outside of the institution?
3) Disclosure
- What information should be shared with the patient/family? Who will be present when this occurs?
4) Investigation
- What is the process for immediate and long-term internal investigation of an error?
5) Improvement
- What process will ensure that immediate and long-term preventative actions are taken?
Root Cause Analysis:
**- is a retrospective investigation of an event that has already occurred, which includes reviewing the sequence of events that led to the error.
- the information obtained in the analysis is used to design changes that will hopefully prevent future errors.
- What happened primarily, that caused the event to occur.
Reporting:
what should be reported?
- medication errors
- preventable adverse drug reactions
- hazardous conditions
- “close calls” or “near misses”
Should be reported.
-Medication errors are reported so that changes can be made to the system to prevent similar errors in the future. Without reporting, these events may go unrecognized and will likely happen again because others will not learn from the incident.
Reporting:
Community Pharmacy:
- Staff member who discovers the error reports to corporate office (follow designated reporting structure)
OR
- To the owner of an independently owned pharmacy
- Report within 48 hours (state specific) [Document and begin RCA]
- Many states require that the patient and prescriber are also notified as soon as possible
“The fundamental purpose of reporting systems is to learn how to improve the health care delivery process to prevent errors.”
- Many state boards of pharmacy require quality assurance programs to promote pharmacy processes that prevent medication errors.
Reporting:
Hospital:
-** report via Medication Event Reporting System - MERS
- **report to Pharmacy & Therapeutics committee and Medication Safety Committee
Organizations that specialize in error prevention:
- The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of Patient Safety Organizations (PSOs)
- The Agency for Healthcare Reseach and Quality (AHRQ) administers the provisions of the Patient Safety Act and rules for PSOs
- The ISMP National Medication Errors Reporting Program (MERP): confidential national voluntary reporting program
[ISMP- Institute for Safe medication Practices] - On the ISMP website (www.ismp.org), medication errors and close calls can be reported.
- Click on “Report Errors”
- ISMP National (MERP) Medication Errors Reporting Program: is a confidential, voluntary reporting program
- ISMP website (www.ismp.org), medication errors and close calls can be report
Evaluation & Quality Improvement:
Can be performed _______
- prospectivity
- retrospectively
- continuously
Evaluation & Quality Improvement:
Prospective-
prospective analysis
(FMEA) Failure Mode & Effects Analysis:
- is a proactive method used to reduce the frequency and consequences of errors. FMEA is used to analyze the design of a system in order to evaluate the potential for failures and to determine what potential effects could occur when the medication delivery system changes in any substantial way OR if a potentially dangerous new drug will be added to the formulary.
Evaluation & Quality Improvement:
Retrospective-
(RCA) Root Cause Analysis:
- is a retrospective investigation of an event that has already occurred, which includes reviewing the sequence of events that led to the error. The information obtained in the analysis is used to design changes that will hopefully prevent future errors.
RCA
Identify the problem
Define the problem
Understand the problem
Identify the root cause
Corrective action
Monitor the system
Evaluation & Quality Improvement:
Continuous-
(CQI) Continuous Quality Improvement:
- is the goal for most healthcare settings.
- CQI programs improve efficiency, quality, and patient satisfaction while reducing costs.
ex. Lean and Six Sigma, which are often used together. Lean focuses on minimizing waste, while Six Sigma focuses on reducing defects.
Six Sigma uses DMAIC (define, measure, analyze, improve, control) process.
Reporting- Adverse Drug Reactions:
- at MedWatch Food and Drug Administration
Evaluation & Quality Improvement:
A root cause analysis (RCA) retrospective analysis of the sequence of events that led to the error.
Identifying the sentinel event: is an unexpected occurrence involving death or serious physical or psychological injury of a patient.
Findings from the RCA are used to improve the system and prevent repeated events.
At-Risk Behaviors that can compromise Patient Safety:
Drug and Patient-Related:
- failure to check/reconcile home medications and doses
- dispensing medications without complete knowledge of the medication
- not questioning unusual doses
- not checking/verifying allergies
Communication:
- Not addressing questions/concerns
- Rushed communication
Technology
- Overriding computer alerts without proper consideration
- Not using available technology
Work Environment
- Trying to do multiple things vs. focusing on a single complex task
- Inadequate supervision and orientation/training
The Joint Commission (TJC):
- Independent, not-for-profit organization that accredits and certifies more than 17000 healthcare organizations and programs in the US, including hospitals.
- TJC: they are concerned about safety and standards, with onsite visits
-TJC focuses on the highest quality and safety of care and SETS standards that institutions must meet to be accredited. - An accredited organization must undergo an on-site survey at least every 3 years, and surveys can be unannounced.
not for community pharmacies but for hospitals, infusion centers, long term care facilities,
“Hospitals are Accredited by The Joint Commission (TJC)”
- if you do not pass the accreditation, Medicare will not pay for services at that hospital.
National Patient Safety Goals (NPSGs):
) Use at least 2 patient identifies when providing care, treatment and services.
What are appropriate patient identifiers?
What are inappropriate patient identifiers and should NOT be used?
——————————————————————————————————————
) Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
What elements should be included?
) Maintain and communicate accurate patient medication information.
What does this include?
What are appropriate patient identifiers?
- patients name
- patients DOB
- medical record number
What are inappropriate patient identifiers and should NOT be used?
- zip code
- room number
- physician name
——————————————————————————————————————–
- There are many important elements to this goal, including the requirements to use approved
- dosing protocols & programable pumps (e.g. for heparin) and to provide education to patients and families.
- Protocols should include STARTING DOSE ranges, ALTERNATE DOSING STRATEGIES to address drug-drug interactions.
- COMMUNICATION with the dietary department to ADDRESS DRUG-FOOD INTERACTIONS, general monitoring requirements and monitoring for bleeding and heparin-induced thrombocytopenia.
———————————————————————————————————————————-
- This includes MEDICATION RECONCILAITION, providing written information to the patient and CONDUCTING DISCHARGE COUNSELING. The medication name, dose, frequency, route, and indication (at a minimum) should be confirmed.
National Patient Safety Goals (NPSGs): [These are from The Joint Commission]
- ## Label all medications on and off the sterile field. Label all medication containers (e.g. syringes) and other solutions on and off sterile field in perioperative and other procedural settings.
- ## Reduce harm associated with anticoagulant therapy
- ## Maintain and communicate accurate patient medical information
- ## Report critical results (labs tests and diagnostics procedures) on a timely basis
- ## Comply with CDC or WHO (world health organization) hand hygiene guidelines
- ## Reduce healthcare associated infections
- Improve the safety of clinical alarm systems
“infection picked up in a healthcare setting” =
Nosocomial “Hospital Acquired”
While TJC is the most recognized accreditation body, 3 other organizations accredit and certify healthcare programs:
1
2
3
1- DNV GL Healthcare
2- Healthcare Facilities Accreditation Program-Accreditation Association for Hospitals/Health Systems (HFAP/AAHHS)
3- (CIHQ) Center for Improvement in Healthcare Quality
Common Methods To Reduce Medication Errors:
- Avoid “DO NOT USE” abbreviations
- ## Abbreviations are unsafe and contribute to many medical errors. TJC standards include recommendations against the use of unsafe abbreviations.
- ## The minimum list of “DO NOT USE” abbreviations per TJC is shown in the table.
- The (ISMP) Institute for Safe Medical Practices, also publishes a list of error-prone abbreviations, symbols, and dosage designations which include those on TJC’s list and may others
DO NOT USE:
Potential Problem:
Use instead:
DO NOT USE: U, u (unit)
Potential Problem:
Use instead:
Potential Problem: Mistaken for “0”(zero), the number 4 (four) or cc
Use instead:
Write “unit”
DO NOT USE: IU (international unit)
Potential Problem:
Use instead:
Potential Problem: Mistaken for IV (intravenous) or the number 10 (ten)
Use instead:
Write “international unit”
DO NOT USE:
Q.D, QD, q.d. (daily)
Q.O.D, QOD, q.o.d
qod (every other day)
Potential Problem:
Use instead:
Potential Problem:
- Mistaken for each other.
- Period after the Q mistaken for “I” and “O’ mistaken for “I’
Use instead:
Write “daily”
Write “every other day”
DO NOT USE:
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
Potential Problem:
Use instead:
Potential Problem:
- Decimal point is missed resulting in a 10-fold dosing error
Use instead:
Write X mg
- Do NOT Use a trailing zero.
Write 0.X mg
- must use a leading zero.
DO NOT USE:
MS
Potential Problem:
Use instead:
Potential Problem:
- can mean morphine sulfate or magnesium sulfate
Use instead:
- Write “morphine sulfate”
