Medication Safety & Quality Improvement Flashcards
Formal definition of a medication error
any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer
Adverse drug reactions vs medications
ADRS = not avoidable, can be more likely if given to high risk pt tho
Close call or near miss error is when….
error or situation occurred but was corrected before reaching the patient
A sentinel event is…
an unexpected occurrence, involving death or serious physical or psychological injury of a patient
Error of omission
something was left out that is needed for safety
Error of Commission
something was done incorrectly
How soon should error investigation take place?
48hrs within incident
MERP
medication errors reporting program = confidential, voluntary reporting program
Prospective evaluation and quality improvement
failure mode and effects analysis (FEMA) method used to reduce frequency and consequences of errors
Retrospective evaluation and quality improvement
root cause analysis (RCA) = retrospective investigation of event that has already occurred, which includes reviewing sequence of events that led to error
Continuous evaluation and quality improvement
Continuous quality improvement (CQI) goal for most healthcare settings
Lean and Six Sigma
Lean = reducing waste
Six Sigma = reducing defects
Joint commission (TJC)
independent, not for profit organization that accredits and certifies healthcare organizations in USA
organization has onsite visit every 3 years, unannounced
Two patient identifiers appropriate for pharmacists
Patient name
medical record number
date of birth
inappropriate patient identifiers for pharmacists
zip code
room number
physician name
N
Do not use abbreviations
U, u = write unit instead
IU = write international unit instead
Q.D/Q.O.D/QD = write out instead
using trailing 0, X.0 or lack of leading zero .X = write 1mg or 0.1mg
MS = mag sulfate vs morphine confusion
Tall man lettering
draws attention to the dissimilarities in the drug names
High alert medications are….
drugs with a heightened risk of causing significant patient harm if used in error
Medication reconciliation
involves comparing a patients new medication orders to all the medications that they had been taking at home.
The 5 rights of medication administration
right patient
right time and frequency
right dose
right route
right drug
