Medication safety and errors Flashcards
what is a medication error?
Any preventable event that may cause or lead to inappropriate mediation use or patient harm, when it is in the control of the professional, patient or consumer
Why do we need medication safety?
Reduce errors, reduce hospital admission (and ADRs) and reduce errors in administration.
We also must take care with high risk medications e.g NSAIDS, anti-coagulants, anti-platelets, anti-hypertensives, diuretics
what is the duty of candour?
legal duty of all trusts to inform, apologise to patients if mistakes have been made in their care that have resulted in significant harm.
Also - speaking up when other things go wrong.
Help patients receive accurate and truthful information, contributing to the transparent culture in the health provision - openesss in error and harm
what are all bodies registered with?
The care quality commission in which they must all comply with the statutory duty of candour
what strategies can we take to reduce medication errors? (5)
clinical decision support systems utilisation of clinical pharmacists double checking medication orders education and training incident reporting
what are the RPS standards for incident reporting? (6)
1- open and honest 2- report 3- learn 4- share 5- act 6- review
what are the reasons why people don’t report incidents?
Time and workload pressure
lack of knowledge - how to report, to who, and what to report, or don’t know of support networks
how can we encourage people to report?
Design and improve reporting, learning an shearing systems so they are easy and quick to use e.g mobile apps, online (technology)
Raise awareness of the local processes of incident reporting, and tools to help with this. Encourage individual reflection and CPD as an incident can be an indication of a learning need
Make aware the patient safety networks across the UK e.g freedom to speak guardians - use leadership to help staff
importance of medication error reporting to the MHRA?
via the yellow card - report side effects.
Some people may experience side effects that aren’t in the PIL, so if we report we can increase awareness
reports are analysed and warnings may be added to packaging to benefit patients
it makes medicines safer and leads to better prescribing
what changes can be done to practice in pharmacy to reduce errors?
changing packaging to avoid mix ups
change connecters on intrathecal injections
tabarts for drug rounds
greater control in monitoring warfarin
what are Never events?
Serious incident that meets the requirements:
wholly preventable
potential to cause serious harm/death
evidence that it has occurred in the past through reports to the NRLS and risk of recurrence remains
easily recognised and clearly defined as a never event
Examples of never events
Wrong route of drug administration
mis selection of the wrong potassium chloride solution
falls from poorly restricted windows
blood transfusion incompatibility
How can we report at Local level?
Near miss error log - Date/time Drug name type of near miss learning points/consideration points possible causes action taken potential adverse event discussion
what is the human factors approach to reducing medication errors?
It is about accepting that majority of people come to work to do a good job. Mistakes are usually caused by ineffective systems.
Systems should be in place to make it easy to do the right thing
create a culture where human error is seen as a source of learning
taking responsibility for safety
