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a PR3145 > Medication Safety l > Flashcards

Medication Safety l Flashcards

1
Q

Definition of Just Culture (2)

A
  • create a system of workplace justice that foster open reporting while holding people accountable for their actions
  • creates a culture of accountability & it is not punitive nor blame free
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2
Q

Human error (2)

A
  • unintentional

- acceptable behaviour but have to improve systems to reduce the risk of medication errors

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3
Q

At-risk behaviours (2)

A
  • risk is not recognised & believed to be justified

- important to coach & teach them on the their risky behaviours

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4
Q

Benefits of just culture (4)

A
  1. Creates psychological safety for staff to report errors
    - not punitive nor blame free
  2. Use common language to consistently & fairly evaluate human behaviours
  3. Shift focus from errors & outcomes to improving system designs & behavioural choices
    - why did it happen
    - how to make system safer for humans
  4. Creates a culture of accountability, not punitive nor blame free
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5
Q

Adverse Drug Event (ADE) (2)

A
  • injury due to medication
  • may or may not be preventable
preventable (eg medication error)
not preventable (eg ADR/SE)
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6
Q

Side effects definition (SE) (3)

A
  • known effect
  • may be primarily intended (off-label use)
  • related to the pharmacological properties of a medication
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7
Q

Adverse Drug Reaction definition (ADR) (2)

A
  • noxious & unintended response to a medication
  • excludes injuries due to medication errors

eg allergic reactions for the first time

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8
Q

Medication error definition (2)

A
  • is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of HCP, patients & consumers (medication use process)
  • such events may be related to procedures, practices, healthcare products or systems
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9
Q

Types of results from medication error (3)

A
  1. Adverse event which patient is harmed
  2. Near miss which patient is nearly harmed
  3. Neither harm nor potential for harm
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10
Q

Near miss (4)

A
  • aka close call
  • an event or situation that could have resulted in medication error but did not due to chance or timely intervention
  • if ignored, it may lead to medication errors
  • occurs 10-100x more often than adverse events
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11
Q

Major injury : Minor injury : Near misses (no injury accidents)

A

1 : 29 : 300

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12
Q

**

Examples of medication errors (3)

A

**
- wrong technique
eg inappropriate crushing of tablets

  • monitoring error
    eg contraindicated drugs, allergies
  • deteriorated drug error
    eg dispense expired drug
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13
Q

Where do errors occur?

A
  • occur at any point in the medication use process

Hence, consider the safety at each step of the medication use process

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14
Q

MUP (4)

A

Medication Use Process

  1. Prescription
    - individualise treatment
  2. Preparation & dispensing
    - transcription of prescription into system
    - counselling
  3. Administration
  4. Monitoring
    - any ADR or side effects
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15
Q

**
% of errors in MUP

Prescription
Administration
Transcription
Dispensing

A

**
Prescription (39%)
- 48% intercepted

Administration (38%)

Transcription (12%)

Dispensing (11%)
- 2% intercepted

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16
Q

Prescribing process (3)

A
  • choose appropriate medication for a given clinical situation, taking individual patient factors into account
    eg allergies
  • communicate details of medication plan
  • documentation
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17
Q

**

Examples of how prescribing can go wrong (4)

A
  • *
  • wrong patient
  • inadequate communication
  • documentation is illegible, incomplete & ambiguous (vague)
  • incorrect data entry when using computerised prescribing
18
Q

Dispensing process (5)

A
  • transcription of prescription
  • review & confirm prescription
  • distribution of medication to patient location
  • documentation
  • dispense drug & patient counselling
19
Q

**

Examples of how dispensing can go wrong (3)

A

**
- transcription error
- poor inventory control
eg look-alikes & sound-alikes placed together, dispensing expired drugs
- documentation is illegible, incomplete & ambiguous (vague)

20
Q

The 5 Rights

A

Right

  • drug
  • route
  • dose
  • time
  • patient
21
Q

**

Examples of how administration of medication can go wrong (3)

A
  • *
  • 5 wrongs (drug, route, dose, time & patient)
  • omission of dose or failure to administer
  • inadequate documentation
22
Q

Monitoring process (4)

A
  • observe for effectiveness / therapeutic effectiveness
  • monitor for ADR / intolerable SE
  • appropriate use of medication
  • documentation
23
Q

**

Examples of how monitoring can go wrong (2)

A
  • *
  • lack of monitoring for effectiveness / therapeutic effectiveness
  • lack of monitoring for ADR / intolerable SE -> cannot provide timely intervention to prevent harm from reaching patient
24
Q

Factors contributing to medication errors (4)

A
  1. Patient factors
  2. Medication / Technology design factors
  3. Staff / Human factors
  4. System / Workplace factors
25
Q

Patient factors examples (5)

A

Certain patients have higher risk of medication errors

  • polypharmacy
  • multiple comorbidities
  • more than 1 doctors
  • children & babies
  • unable to communicate
26
Q

Medication / Technology design factors (2)

A
  1. Poor drug manufacturing / distribution practices

2. Complex or poorly designed technology

27
Q

**

Examples of complex or poorly designed technology (3)

A
  • *
  • confusing dosage form (eg Spiriva Handihaler & its drug capsule for inhalation)
  • parental, enteral & luer connecters can fit with other non-specific device
  • automated distribution, vending systems, counting machines & compounders
28
Q

Staff / Human factors

A
  • failed communication

eg illegible handwriting, confusion among drugs

29
Q

System / Workplace factors (3)

A
  • absence of safety culture in workplace
  • inadequate training or supervision
  • inadequate staff numbers or staffing arrangement
30
Q

Why do errors occur? (2)

A
  • occur as a result of “a chain of events set on motion by faulty system design that either induces errors or makes them difficult to detect” rather than lack of care & concern on the part of our caregivers
  • human error contribute largely but most are induced by system failures
  • problem lies with the system
    Hence system has to be made safe
31
Q

The Swiss Cheese model of harm

A
  • both latent conditions & active failures (unsafe acts) contribute to harm
  • harm results when the layers of defence in a system fail to prevent a hazard from reaching a patient
32
Q

Importance of identifying & addressing latent errors or system failures (4)

A
  • pose greatest threat to safety in a complex system
  • they are failures built into the system & present long before the active error
  • hidden
  • people become accustomed to working around it
33
Q

Issues with current response to errors (4)

A
  • focus on active errors by punishing individuals, retraining etc
  • these are not effective in making system safer
  • if latent failures remain unaddressed, accumulation of latent errors can make the system more prone to future failures
  • discovering & fixing latent failures have greater effect on building safer systems than efforts to minimise errors at the point which they occur
34
Q

Report & learning from medication errors & near misses (2)

A
  • reporting involves collecting & analysing information about the adverse event that have harmed or potentially harm a patient
  • learning through Root Cause Analysis
35
Q

RCA definition (2)

A

Root Cause Analysis

  • a systematic approach to understand the cause of an adverse event & identifying system flaws (latent errors) that can be corrected to prevent the error from happening again
  • focus on system causes & vulnerabilities > blaming
36
Q

Simplified RCA

3 questions

A
  1. What happened? Describe the key steps
  2. What went wrong & why? Identify the failed processes
  3. What to do to prevent incident recurrence? Suggest risk reduction strategies & their implementation
37
Q

Systems approach to error

A
  • focus on system causes > blaming individual
38
Q

RCA team

A
  • 4-6 people

- interprofessional

39
Q

Deteriorated drug error

A
  • dispense expired medications
40
Q

Greatest contributor to medication error

A
  • human error
  • but human are victims of poor system design which induces errors or makes them difficult to be seen / identified to be addressed

a PR3145 (14 decks)

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