Medication Safety & Quality Improvement Flashcards
These two organizations are actively involved in improving medication safety
The Joint Commission
The institute for safe medication practices (ISMP)
Define medication error that was developed by the 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 the medication is in the control of the PCP, patient, or consumer.”
This event is an unexpected occurrence involving death or serious physical or psychological injury or risk thereof.
Sentinel event
Institutions should have a plan in place for responding to med errors that involve:
Internal notification External notification Disclosure Investigation Improvement
Who reports the error?
In a pharmacy, the staff members who discovers the error should immediately report it to the owner (if independent pharmacy), corporate office, etc
Error investigations need to take place within __ hrs
48
Which hospital committee’s need to be informed of the error?
P&T, Med safety committee
An organization that is a confidential, voluntary reporting program that provides expert analysis of the system causes of med errors and provides recommendations for prevention
ISMP National Medication Errors Reporting Program (MERP)
Med errors and close calls can be reported on what website
ISMP.org
How can evaluation and quality improvement be performed?
Prospectively, retrospectively, and continuously
Failure more and effects analysis (FMEA) is a ____ method used to reduce the frequency and consequences of errors
Proactive
A root cause analysis is a _____ investigation of an event that has already occurred which includes reviewing the sequence of events that led to the error
Retrospective
________ is the goal for most healthcare settings. Examples: Lean (minimizing waste), Sigma Six (reducing defects)
Continuous quality improvement
An independent, not-for profit organization that accredits and certifies healthcare organizations
JCO
JCO accredits what organizations and programs?
Hospitals healthcare networks LTCF home care organizations office-based surgery centers independent laboratories
National patient safety goals are set how frequently by JCO?
annually
All institutions accredited by JCO are required to have a list of what in their facility?
list of abbreviations
High-alert meds can be used safely by developing protocols or order sets for use, using ____ products whenever possible, limiting concentrations available in the institution and stocking the high alert products where?
premixed products
only in the pharmacy
List the select high-alert meds
anesthetics, IV, or inhaled (ex: propofol) antiarrhythmics, IV anticoagulation, heparin Methotrexate Hypertonic saline Cyclosporine Digoxin Insulin U-500 Mg sulfate inj TPN Opioids PCl and phosphates for inj Sulfonylureas Steril water for injection
What should you never rely on to indentify the right drug product?
Drug packaging
Medications in crash carts should be _____ and ______
unit dose and age specific
________ may be the most important error reduction tool currently available
Barcoding
JCO requires what in order to remove meds from an automated dispensing cabinet?
a pharmacist review the order; ONE exception is overrides but these should be investigated
What medications should not be put in ADCs?
insulin, warfarin, high dose narcotics
Contact precautions are recommended for patients colonized or infected with:
VRE, MRSA and C dif
Airborne precautions are recommended for patients with:
active TB, measles, or varicella virus (chickenpox)
When should you use soap and water vs alcohol based rubs?
C Dif
before caring for patients with food allergies
