Medication Safety & QI Flashcards
the term “medication safety”
freedom from preventable harm due to medication use
formal definition of medication error
developed by National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
“any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in the control of the healthcare professional, patient, or consumers”
ADRs vs Medication errors
ADRs are not usually not avoidable, more likely to occur if the drug is given to pt at high risk for certain complications
medication error made by prescriber or pharmacists
sentinel error
unexpected occurrence involving death or serious physical or psychological injury of a pt. when a sentinel event occurs, it is important to find out what went wrong and implement preventive measures.
system-based error
most common cause of med errors is a problem with the design of the medical system itself, not usually the healthcare worker
At-Risk behaviors that can compromise patient safety
Drug and pt-related
- Failure to check/reconcile home meds and doses
- Dispensing meds w/o complete drug knowledge
- not questioning unusual doses
- not checking/verifying allergies
At-Risk behaviors that can compromise patient safety
Communication
- not addressing questions/concerns
- Rushed communication
At-Risk behaviors that can compromise patient safety
Technology
- overriding computer alerts w/o proper consideration
- not using available technology
At-Risk behaviors that can compromise patient safety
work environment
- trying to do multiple things vs focusing on a single complex task
- inadequate supervision and orientation/training
Response
responding to med errors
- internal notification: within the institution and within what time frame
- External reporting: who should be notified outside of the institution
- Disclosure: what information should be shared with pt/family, who will present
- investigation: process..
- improvement: actions ..
Errors of Omission
Something was left out that is needed for safety
ex: failing to use pharmacist double-check system for chemo orders
Errors of Commission
something was done incorrectly
ex: prescribing bupropion to a pt with a history of seizures
within hospitals who should be informed of the error
the hospital’s Pharmacy and Therapeutics committee and medication safety committee (or similar entity) should be informed of the error
MERP
ISMP National Medication Errors Reporting Program (MERP) is a confidential, voluntary reporting system.
provides expert analysis of the system’s causes of med errors and provides recommendations for prevention
Medications errors and close calls
can be reported?
can be reported on ISMP website
The Institute for Safe Medication Practices
Evaluation and QI can be performed prospectively, retrospectively, or continuously
prospectively
prospective: failure mode and effects analysis (FMEA) is a practice method used to reduce the frequency and consequences of error
analyze the design of the system to evaluate potential failures
Evaluation and QI can be performed prospectively, retrospectively, or continuously
retrospectively
A root cause analysis (RCA) is a retrospective investigation of an event that hs already occurred. which includes reviewing the sequence of events that lead to error
Evaluation and QI can be performed prospectively, retrospectively, or continuously
continuously
continuous quality improvement (CQI) is the goal for most healthcare settings.
lean and six sigma
Lean: focuses on minimizing waste
six sigma: focuses on reducing defects (DMAIC: define, measure, analyze, improve, control)
the joint commission
an independent, not-for-profit organization that accredits and certifies more than 20,000 health organizations and programs
under-go an onsite survey at least every 3 years
NPSGs
national patient safety goals (NPSGs) are set annually by TJC
each goal includes an “element of performance”
Important NPSGs for pharmacy
pt identifiers
use at least two pt identifiers
appropriate: pt identifiers, name, medical record number, and date of birth
inappropriate: zip code, room #, physician name
Important NPSGs for pharmacy
anticoagulant therapy
use approved dosing protocols and programmable pumps, and provide education to pt and families.
protocols should include, starting dose ranges, and alternate dosing strategies to address drugs-drug interactions, communication w/ the dietary department to address drug-food interactions, general HIT monitoring
Important NPSGs for pharmacy
pt med info
maintain and communicate accurate pt medication info
- includes med reconciliation, provide written info to pt and conducting discharge counseling
NPSG 01.01.01
use at least two pt identifiers when providing care, tx and service
NPSG 02.03.01
report critical results of test and diagnostic procedures on a timely basis
