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PR3145 > Medication Safety > Flashcards

Medication Safety Flashcards

1
Q

Define Side effect

A

Known effect

  • Other than primarily intended
  • Related to pharmacological properties of drug

i.e. opiates analgesia often cause nausea

(CCL: unintended effect occurring at normal dose related to the pharmacological properties)

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2
Q

Define Adverse drug reaction (ADR)

A

Any noxious and unintended response to a medication

  • Includes drug related injuries (idiosyncratic rxn)
  • Exclude drug related injuries due to errors, overdose, drug abuse

-i.e. allergic reactions for pt taking medication for 1st time

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3
Q

What is the 2nd victim phenomenon?

A

The Healthcare professionals (HPs) involved in a ADR event

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4
Q

Define Adverse Drug Event

A
  • Injury due to medication
  • May be preventable* or non-preventable**
  • Costly (significant resource consumption)
  • i.e. known allergies
  • *i.e. unknown allergies
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5
Q

Define medication error

A
  • Any preventable event that may lead to inappropriate medication use or pt harm
  • While medication is in control of HP/pt/consumer
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6
Q

What are the possible consequences of medication errors?

A
  1. Adverse event with pt harm
  2. Near miss where pt was nearly harmed
  3. No harm/potential for harm
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7
Q

What are some types of medication errors?

A

Wrong: dose, pt, drug, conc, formulation, ROA, technique, rate, duration, time

  • Dose omission
  • Monitoring error
  • Deteriorated drug error (incl. expiry)
  • Others
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8
Q

Define near misses

A

An event with potential to cause medication error

  • But did not (chance/intervention)
  • aka close calls
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9
Q

Can we afford to ignore near misses since they did not result in any harm?

A

If near misses are ignored, they may lead to medication errors

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10
Q

What does the Heinrich ratio tell us about adverse events?

A

Sentinel : Minor injury : Near misses ratio is 1 : 29 : 300

- Close calls happen 10-100X more frequently than adverse events

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11
Q

How many categories of Patient outcomes are there when it comes to medication error?

A

A-I (9 categories)

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12
Q

What is a category A error?

A

Potential for error

  • No error has occurred YET
  • usually un-noticed and unreported
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13
Q

What is a category B error?

A

Error occurred but did not reach pt

  • i.e. pcist interventions
  • Most commonly reported
  • near miss
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14
Q

What is a category C error?

A

Error occurred that reached pt w/o harm

  • but did not cause harm
  • i.e. dose errors for high TI drug, pt was able to tolerate
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15
Q

What is a category D error?

A

Error occurred that reached pt w/o harm

  • Required monitoring to confirm no harm AND/OR
  • Required intervention to prevent harm
  • i.e. monitoring for AG nephrotoxicity after AG overdose, where pt did not get nephrotoxicity
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16
Q

What is a category E error?

A

Error occurred that reached pt

  • May have contributed towards harm OR
  • Resulted in temporary harm
  • Required intervention
  • i.e. AG overdose -> pt developed transient nephrotoxicity
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17
Q

What is a category F error?

A

Error occurred that reached pt

  • May have contributed towards harm OR
  • Resulted in temporary harm
  • Required initial/prolonged hospitalization (short/long term)
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18
Q

What is a category G error?

A

Error occurred that reached pt

  • May have contributed towards harm OR
  • Resulted in permanent harm (can be morbidity or psychological)
  • i.e. overdose of warfarin –> cerebral bleed (pt got stroke but did not return to baseline function)
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19
Q

What is a category H error?

A

Error occurred that required intervention necessary to sustain life*
- i.e. pt became comatose

*CVS/respiratory support (CPR, defibrillation, intubation)

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20
Q

What is a category I error?

A

Error resulted in/contributed to pt’s death

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21
Q

What is the scale of medication error?

A
  • 1/10 pts harmed while receiving care
  • 43 million incidences/year
  • $USD 42 billion cost/year
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22
Q

Which points of the medication use process are error prone?

A

All of them

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23
Q

What is the general medication use process?

A
  1. Prescribing
  2. Preparation/dispensing
  3. Administration
  4. Monitoring
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24
Q

Why do administration errors have a low interception rate?

A

administration work usually done alone

  • no double checking
  • little interception = more harm
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25
Q

What does the prescribing process involve?

A
  1. Choosing appropriate medication for pt (taking individual factors into account i.e. allergies)
  2. Selecting ROA, drug, dose, regimen, time
  3. Communicating plan with pt and whoever is administering drug (written/verbal comms)
  4. Documentation
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26
Q

How can prescribing go wrong?

A
  1. Inadequate knowledge on drug (unfamiliar) (on indication/CI)
  2. Not considering individual pt factors
  3. Wrong pt/drug/dose/regimen
  4. Inadequate communication
  5. Illegible/incomplete/ambiguous documentation
  6. Math error on dose calcs
  7. Incorrect data entry (duplicates, omission, wrong number)
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27
Q

What does the dispensing process involve?

A
  1. Transcribing prescriptions
  2. Review and confirmation of prescription
  3. Preparation and/or packing of meds
  4. Distribution to pt location
  5. Documentation
  6. Dispensing and pt counselling
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28
Q

How can dispensing go wrong?

A
  1. Poor inventory control*
  2. Mixing up labels/packaging
  3. Transcription error**
  4. Failure to check for individual patient factors
  5. Illegible/incomplete/ambiguous documentation
  6. Math error on dose calcs
  7. Miscommunication
  • i.e. placing LASA meds tgt, not implementing first in, first out
  • *esp manual transcription (nursing homes)
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29
Q

What does the administration process involve?

A
  1. Obtaining medication in ready-to-use form*
  2. Checking for allergies
  3. Right medication/pt/dose/regimen/time/ROA
  4. Documentation

*May include count/calc/mix/label/preparations, esp IV items need to be reconstituted

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30
Q

How can administration go wrong?

A

Wrong: drug, ROA, time, dose, pt

  • Omission*
  • Inadequate documentation/communication

*i.e. pt absent at bedside when scheduled for dose + no follow up

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31
Q

What does the monitoring process involve?

A
  • Observing pt to look for medication
    1. Therapeutic effects
    2. ADRs
    3. Documentation
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32
Q

How can monitoring go wrong?

A
  • Lack of monitoring for ADRs
  • Not stopping ineffective/completed tx
  • Stopping drug before full duration of tx
  • Not measuring drug levels or following up
  • Communication failure
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33
Q

What are the pt factors that contribute to error?

A
  1. Polypharmacy or multiple health conditions
  2. > 1 doctor*
  3. Specific conditions (pregnant/renal impairment)
  4. Inability to communicate well
  5. Pts who do not take active role in med use
  6. Children and babies (special dose calcs)

*Can be overcome via med recon

34
Q

What are the drug manufacturing/distribution (medication/technology) factors that contribute to error?

A
  • LASA* meds (vs other concs/drugs/formulation)
  • Poor packaging design
  • Inaccurate/incomplete label**
  • Misleading/confusing information
  • Distracting symbols/logo
  • looks too similar to another manufacturer
  • looks too similar within the same company’s product line
  • similar in color/shape/size to another pdt or same pdt but diff strength
  • Look alike, sound alike
  • *i.e. when cutting strips, expiry date and strength on back of strip cut partially
35
Q

What are the technology factors that contribute to error?

A
  • Malfunction
  • Wrong device (i.e. swallowing spiriva capsules instead of using handihaler)
  • Multi-function adapters*
  • Automated technologies
  • Oral measuring devices (i.e. oral and IV syringes looking the same or inaccurate markings)
  • Infusion

*i.e. IV adapter that accepts oxygen tubing, parenteral vs enteral, luer connectors

36
Q

What are the situations where staff are more likely to cause medication error?

A
  • Incompetence
  • Complacency
  • Rushing
  • Distracted, Interrupted*
  • Fatigue, boredom (auto pilot)
  • Lack of checking and double checking
  • Violation of SOP/protocol
  • Not using memory aids
  • Poor teamwork/communication

*No phones when working

37
Q

How can failed communication arise?

A

Confusion

  • LASA (drugs w similar names)
  • Wrong formulation/conc (LA,CR,SR)
  • Missing/Misplaced zeroes and decimal points
  • Units of measure
  • Non-standard abbreviations*
  • Ambiguous/Incomplete orders
  • Illegible handwriting

*10U looks like 100

38
Q

What are some system/workplace factors that contribute to errors?

A
  • Lighting and noise level
  • Frequent distractions/interruptions
  • Absence of safety culture
  • Inadequate training/supervision
  • Absence of readily available meds/pt info
  • Inappropriate storage of meds
  • Inadequate staffing*
  • Breakdown of information system

*inexperienced staff assigned, lack of staff

39
Q

Why do errors occur?

A

Mostly due to a chain of events set in motion by

  • Faulty system design that induces errors or make errors difficult to detect
  • rather than lack of care/concern by HPs
  • Greatest contributor is human error induced by system failures
40
Q

Why do latent errors/system failures pose the greatest threat to safety in a complex system?

A
  1. They lead to operator errors
  2. Difficult for people working in the system to see as it might be hidden in computers/layers of management –> people become accustomed to working around it

*latent errors are built into the system and present long before the active error

41
Q

How should we react appropriately when an error occurs?

A
  1. Blaming individuals does not change latent errors, error likely to recur
  2. Errors represent places where there are system failures, where system breakdown resulted in harm
  3. Adopt a systems approach* to prevent errors and avoid harm (discover/fix/reduce duration of latent errors)

*Root cause analysis (RCA)

42
Q

What is one method to find latent errors?

A

Use Incident reporting system

  • Collect and analyze* info on near misses or events that resulted in pt harm
  • Lessons learnt can help identify and eliminate latent errors

*Root cause analysis (RCA)

43
Q

What is root cause analysis (RCA)?

A

Systematic approach to understand causes of adverse events

  • Analyzes ALL contributing factors to error, not just the error itself
  • Identifies latent errors (system flaws) to be corrected to eliminate error

*More effective than blaming individual who made the mistake

44
Q

It is known that RCA is conducted by a Pt safety team. What makes up the team?

A
  • Inter-professional team of 4-6 people

Include individuals:

  • at all levels of the organization
  • close to issue
  • have fundamental knowledge of issues/process involved
45
Q

What are the 3 key questions of a RCA?

A
  1. What happened? Describe the key steps
  2. What went wrong and why? Identify the failed processes*
  3. What to do to prevent incident recurrence? Suggest risk reduction strategies and their implementation

*i.e. inexperienced staff assigned, lack of staff

46
Q

Under the hierarchy of effectiveness, what are some examples of LOW leverage risk mitigation strategies?

A

Person based:

  • Rules and policies (i.e. policy inhibiting borrowing doses from other areas)
  • Education and information

*low effectiveness but cannot be ignored

47
Q

Under the hierarchy of effectiveness, what are some examples of MEDIUM leverage risk mitigation strategies?

A

Person based:
- Reminders, checklists, double checks
System based:
- Simplification and standardization

48
Q

Under the hierarchy of effectiveness, what are some examples of HIGH leverage risk mitigation strategies?

A

System based:

  • Forcing functions and constraints (i.e. removal of product)
  • Automation/computerization (i.e. automated pt specific dispensing)
49
Q

How can we reduce reliance on human memory? (To reduce errors)

A
  • Use DDI checking systems
  • Use computerized order entry (i.e. pop up alerts, lexicomp)
  • Use barcoding on drugs, containers, med records, pt wristbands (avoid manual checking)
  • Use computerized pt information (easier checking)
  • Use guided dose algorithms (clinical decision support i.e. automatic CrCl calculators)
50
Q

Are automated systems completely safe?

A

No. They can amplify any upstream errors i.e. wrong drug being topped up/mislabeling

51
Q

How can we simplify things? (To reduce errors)

A
  • Limit drug choices in pharmacy
  • Limit dosage strengths/conc
  • Mix IVs* (prep) in pharmacy
  • Eliminate transcription of orders
  • Automate dispensing on pt care unit

*Avoid calc/reconstitution at the ward

52
Q

What should we standardize? (To reduce errors)

A
  • Prescribing conventions (use generic names, avoid error prone abbreviations)
  • Protocols for complex medication administration
  • Times of drug administration (improve efficiency, reduce distractions)
  • Storage of meds (same place in every med room*)
  • Equipment (1 type of pump/syringe to improv familiarity)

*Easier to familiarize new personnel

53
Q

What are ways to avoid error prone abbreviations?

A
  • Select from electronic drop down menus

- Write out instructions in full

54
Q

How can we utilize forcing and constraints functions? (To reduce errors)

A
  • Special luer-locks syringes and indwelling lines that have to match before fluid can be infused
  • Use computerized order entry with dosage range checks
  • Remove dangerous IV drugs from ward stock
  • Special safeguards for high-alert medications

*Effective method

55
Q

What are 8 special safeguards for high alert medications?

A
  • Improve access to information about these drugs (make sure HPs know indication and dose)
  • Limit access to high alert medications (remove from wards)
  • Limit available number/conc/vol of drug
  • Use auxiliary labels and automated alerts (make labels obvious)
  • Standardize ordering, storage, preparation and administration
  • Automated/Independent double checks when necessary (including for infusion pumps)
  • Close monitoring
  • Change practices to reduce adverse effects of potential errors
56
Q

What are some examples of high alert medications?

A
  • Intrathecal/epidural ROA
  • Anaesthetics
  • Anti-coagulants/thrombolytics
  • Chemotherapeutics
  • Conc. Electrolytes
  • Hypoglycaemic agents
  • Inotropes
  • Insulin
  • Neuromuscular agents
  • Opiates
  • Radio contrast agents
  • Sedatives
  • Vasopressors (i.e. adrenaline)
57
Q

How can we use protocols* and checklists wisely? (to reduce errors)

*Support standardization

A

Checklists: reminder of critical tasks

  • Helps reduce inter-individual variation in practice*
  • Avoid negatives in statement
  • Ensure consensus and awareness of protocols in use
  • Revisit/update/evaluate protocols regularly

*Not to apply indiscriminately (source of error)

58
Q

How can we improve access to information (to reduce errors)

*Lack of info is a common cause of error

A
  • Have a pcist available on nursing units/rounds
  • Use computerized order entry systems (DDI popups)
  • Computerized alerts for abnormal lab data
  • Having labs/med records at bedside
  • Having protocols and ordering info on pt’s charts/med room (accessible)
  • Color-coded wristbands (allergies, fall risk, MRSA, MDR organisms)
  • Provide pts w list of meds/dosage and regimen
  • Track near misses/errors and provide regular feedback
59
Q

How can we decrease reliance on vigilance? (to reduce errors)

There are limits to the human attention span

A
  • Double checks
  • Automatic drug dose checking in high risk situations
  • Electronic monitors that raise alerts when parameters exceeded
  • Rotate staff when performing repetitive functions (avoid boredom and auto-pilot)
  • Limit shift duration for HPs, support personnel (prevent excessive fatigue)
60
Q

How can we reduce handoffs? (to reduce errors)

  • To reduce complexity and info loss
A
  • Ready to administer products
  • Reduce transcription of med orders
  • Use unit-dose system
  • Use automated dispensing/filling systems
  • Use computerized prescriber order entry
61
Q

How can we eliminate LASA medications? (to reduce errors)

A
  • Store similar looking meds in SEPARATE places
  • Repackage/re-label look-alikes
  • Alert staff and post info on LASA medications
  • Avoid stocking look-alike packages
  • Use striking caution stickers on stock containers to alert staff to LASA
  • Use Tall man lettering*

*put in capitals to differentiate the different parts

62
Q

When can automation become hazardous?

A
  • When it leads staff to feel less responsibility for task

- Can multiply error made upstream (i.e. when generating inputs to system)

63
Q

How can we automate carefully?

A
  • Use computerized order entry systems with range checks and override capacity
  • Train staff to double check automation regularly
  • Use barcodes to identify drugs
64
Q

Which tasks are best assisted by automation?

A
  • Repetitive tasks

- Tasks requiring attention to detail

65
Q

What are the advantages of a Computerized order entry (CPOE)?

A
  1. Eliminates writing discrepancies
  2. Immediate error checking
  3. DDI and allergy checking
  4. Can be Information databases if tied to formulary, policies and external data sources
  5. Tool to document administration of meds by nursing
  6. Immediate transmission of orders to multiple disciplines
  7. Providing data to analyze drug utilization and workflow
  8. Increase formulary adherence and compliance to guidelines
  9. Allow price comparisons
  10. Links to databases can provide complete pt info (i.e. labs)
  11. Intelligent prescribing (i.e. automatic dose calculators)
66
Q

What are 6 ISMP key recommendations for safe electronic communication of medications orders?

A
  1. Use generic names (i.e. standardized nomenclature)
  2. Avoid including salts of drugs (unless diff salt = diff function)
  3. Differentiate generic name from brand name
  4. Standardize inclusion of suffixes (LA,CR,SR etc…)
  5. Standardize use of mnemonics or short names
  6. Standardize fonts (size, style, colors)
67
Q

What can a prescriber do BEFORE prescribing to ensure safety?

A
  • Assess pt, ensure drug is appropriate
  • Always ask for allergies, note down undocumented allergies
  • Consider concurrent meds, check for interactions
  • Consider and discuss alternative therapies with pt
68
Q

What can a prescriber do DURING prescribing to ensure safety?

A
  • Check for correct drug, pt, dose, frequency, ROA
  • Use generic names
  • Avoid abbreviations, unnecessary zeroes
  • Include start/review date
  • Check units
  • Refer to references when in doubt
  • Ensure prescription is legible and easy to read
  • Explain rationale of prescribed meds and administration instructions (improve compliance, reduce confusion)
69
Q

What can a prescriber do AFTER prescribing to ensure safety?

A
  • Monitor for ADRs
  • Monitor labs/test results as needed
  • Review pt indications for drugs regularly (remove unnecessary drugs)
70
Q

What should be done to ensure safety DURING processing of order?

A
  • Interpret prescription carefully, identify ambiguity/safety issues and contact prescriber immediately if any
  • Remind prescribers not to use dangerous abbreviations
  • Check correct entry into pt profile
  • DO NOT ignore system allergy/DDI warnings
  • Ensure label is accurate
  • Affix correct label to correct drug
  • Counter check drug against prescription order (NOT against drug label)
71
Q

What should be done to ensure safety DRUING dispensing?

A
  • Check for correct drug and pt
  • Check for allergies, concurrent med use/TCM/DDI
  • Counsel on potential Food-drug interactions
  • Explain rationale and administration instructions
  • Keep up-to-date references accessible for checks when in doubt
72
Q

What should be done to ensure safety BEFORE administration?

A
  • Check for correct med chart, drug for correct pt
  • Interpret order carefully prior to administration
  • Check that new drug orders are reviewed by pcist
  • Check for allergies
  • Check for ambiguous orders and contact prescriber if necessary
  • Get a double check before administration
  • Counter-check drug prepared against order
  • Label all infusion sets and lines
  • Be familiar with different administration sets and devices available in inventory
  • Accept verbal orders only in emergencies by WRITING down and REPEATING BACK the order, spelling the drug NAME and DOSES
73
Q

What should be done to ensure safety DURING administration?

A
  • Check for correct drug and correct pt
  • Counsel on possible ADRs
  • Encourage pt to voice problems/discomfort during administration
74
Q

What should be done to ensure safety ATFER administration?

A

Document promptly on med chart the administration time of drug

75
Q

What are the basic principles of monitoring medication use?

A
  1. Be familiar with drug use protocols, possible ADRs following administration
  2. Be vigilant when monitoring pt (adhere to protocol)
  3. Alert prescriber promptly when pt develops unexpected s/sx or response
  4. Document pt response on med chart in a timely manner
  5. Avoid dangerous abbreviations
  6. Keep up-to-date references for quick checks
76
Q

How can we build a safety driven mindset?

A
  1. Communicate clearly
  2. Collaborate
  3. Be familiar with meds prescribed/dispensed
  4. Pay extra attention to high risk meds
  5. Use memory aids
  6. Develop checking habits, ask for help
  7. Involve and educate pts (listen to them)
  8. Speak up when there are concerns
  9. Report and learn from errors/near misses
  10. Take care of yourself
77
Q

For closed loop medication management system (CLMM), what are the 4 rights of Medication safety?

A

right: patient, drug, dose, time

* right route is for medication administration

78
Q

what does the CLMM comprises of?

A
  1. Electronic inpatient medication record system (eIMR)
  2. clinical decision support system (CDSS)
  3. Inpatient pharmacy automated system
    - dispensing, packaging
  4. Electronic Med Administration Record system (eMARS)
    - enable nurse to administer med correctly to patients
79
Q

what is the ‘just culture’

A

fostered open reporting, while simultaneously, holding people appropriate accountable for their actions

culture of accountability, not punitive nor blame free

shift focus from errors/outcomes to system design and behavioural choices

80
Q

in the just culture, which we dont blame people?

A
  • human error
  • at-risk behaviour

(not for reckless, knowingly causing harm and purposely)

PR3145 (10 decks)

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