Medication Safety l Flashcards
Definition of Just Culture (2)
- 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
Human error (2)
- unintentional
- acceptable behaviour but have to improve systems to reduce the risk of medication errors
At-risk behaviours (2)
- risk is not recognised & believed to be justified
- important to coach & teach them on the their risky behaviours
Benefits of just culture (4)
- Creates psychological safety for staff to report errors
- not punitive nor blame free - Use common language to consistently & fairly evaluate human behaviours
- Shift focus from errors & outcomes to improving system designs & behavioural choices
- why did it happen
- how to make system safer for humans - Creates a culture of accountability, not punitive nor blame free
Adverse Drug Event (ADE) (2)
- injury due to medication
- may or may not be preventable
preventable (eg medication error) not preventable (eg ADR/SE)
Side effects definition (SE) (3)
- known effect
- may be primarily intended (off-label use)
- related to the pharmacological properties of a medication
Adverse Drug Reaction definition (ADR) (2)
- noxious & unintended response to a medication
- excludes injuries due to medication errors
eg allergic reactions for the first time
Medication error definition (2)
- 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
Types of results from medication error (3)
- Adverse event which patient is harmed
- Near miss which patient is nearly harmed
- Neither harm nor potential for harm
Near miss (4)
- 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
Major injury : Minor injury : Near misses (no injury accidents)
1 : 29 : 300
**
Examples of medication errors (3)
**
- wrong technique
eg inappropriate crushing of tablets
- monitoring error
eg contraindicated drugs, allergies - deteriorated drug error
eg dispense expired drug
Where do errors occur?
- occur at any point in the medication use process
Hence, consider the safety at each step of the medication use process
MUP (4)
Medication Use Process
- Prescription
- individualise treatment - Preparation & dispensing
- transcription of prescription into system
- counselling - Administration
- Monitoring
- any ADR or side effects
**
% of errors in MUP
Prescription
Administration
Transcription
Dispensing
**
Prescription (39%)
- 48% intercepted
Administration (38%)
Transcription (12%)
Dispensing (11%)
- 2% intercepted
Prescribing process (3)
- choose appropriate medication for a given clinical situation, taking individual patient factors into account
eg allergies - communicate details of medication plan
- documentation
**
Examples of how prescribing can go wrong (4)
- *
- wrong patient
- inadequate communication
- documentation is illegible, incomplete & ambiguous (vague)
- incorrect data entry when using computerised prescribing
Dispensing process (5)
- transcription of prescription
- review & confirm prescription
- distribution of medication to patient location
- documentation
- dispense drug & patient counselling
**
Examples of how dispensing can go wrong (3)
**
- transcription error
- poor inventory control
eg look-alikes & sound-alikes placed together, dispensing expired drugs
- documentation is illegible, incomplete & ambiguous (vague)
The 5 Rights
Right
- drug
- route
- dose
- time
- patient
**
Examples of how administration of medication can go wrong (3)
- *
- 5 wrongs (drug, route, dose, time & patient)
- omission of dose or failure to administer
- inadequate documentation
Monitoring process (4)
- observe for effectiveness / therapeutic effectiveness
- monitor for ADR / intolerable SE
- appropriate use of medication
- documentation
**
Examples of how monitoring can go wrong (2)
- *
- lack of monitoring for effectiveness / therapeutic effectiveness
- lack of monitoring for ADR / intolerable SE -> cannot provide timely intervention to prevent harm from reaching patient
Factors contributing to medication errors (4)
- Patient factors
- Medication / Technology design factors
- Staff / Human factors
- System / Workplace factors
Patient factors examples (5)
Certain patients have higher risk of medication errors
- polypharmacy
- multiple comorbidities
- more than 1 doctors
- children & babies
- unable to communicate
Medication / Technology design factors (2)
- Poor drug manufacturing / distribution practices
2. Complex or poorly designed technology
**
Examples of complex or poorly designed technology (3)
- *
- 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
Staff / Human factors
- failed communication
eg illegible handwriting, confusion among drugs
System / Workplace factors (3)
- absence of safety culture in workplace
- inadequate training or supervision
- inadequate staff numbers or staffing arrangement
Why do errors occur? (2)
- 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
The Swiss Cheese model of harm
- 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
Importance of identifying & addressing latent errors or system failures (4)
- 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
Issues with current response to errors (4)
- 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
Report & learning from medication errors & near misses (2)
- reporting involves collecting & analysing information about the adverse event that have harmed or potentially harm a patient
- learning through Root Cause Analysis
RCA definition (2)
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
Simplified RCA
3 questions
- What happened? Describe the key steps
- What went wrong & why? Identify the failed processes
- What to do to prevent incident recurrence? Suggest risk reduction strategies & their implementation
Systems approach to error
- focus on system causes > blaming individual
RCA team
- 4-6 people
- interprofessional
Deteriorated drug error
- dispense expired medications
Greatest contributor to medication error
- human error
- but human are victims of poor system design which induces errors or makes them difficult to be seen / identified to be addressed
