Medication Safety & Quality Improvement Flashcards
Chapter 76
What does Medication Safety mean?
- Freedom from preventable harm due to medication use
What are Medication Errors?
- Any Preventable event that may cause or lead to inappropriate medication use or patient harm while in control of healthcare professional
What are adverse drug reactions?
- NOT medication errors; ADRs are not preventable
What is a close call?
- Error that was corrected before reaching the patient
What is a Sentinal event
- Safety error that lead to death, severe harm, or permenant harm
What are the 5 rights of medication safety?
- The Right Patient
- The Right Time/Frequnecy
- The Right Dose
- The Right Route
- The Right Drug
What are the two forms of human error and what is the difference between them>?
- At-risk: thinks the risk is low; makes workarounds
- Reckless: conscious disregard
What are some organizations that focus on patient safety?
- The Institute for Safe Medication Practices (ISMP)
- The Joint Commission
- Center for Medicaid and Medicare Service (CMS)
What is are some of the important National Patient Safety Goals (NPSGs) that pharmacist must follow?
NPSG is from the Joint Commission
- TWO patient idenifiers [name, DOB, pt number…]
- Possible harm from Anticoag [Dosing protocol, Pumps, Alt Dosings, drug-food interactions]
- Accurate Patient information [reconcilliation, DC counseling]
What is a Medication Reconcillation?
5 steps
- List of current medications
- List of drugs to be prescribed
- Compare the 2 lists
- Note differences then stop or hold them
- Tell new list to patient
What are Collaborative Practice Argeements?
- Allows pharmacist to preform advanced care activities [monitor drug levels, adjust doses]
What are some of the errors that should be reported?
- Medication Errors
- Preventable ADRs
- Hazardous Conditions
- “close calls”
- “near misses”
What is prospective evaluation and quality improvments?
- Failure Mode and Effects Analysis (FMEA) is a proactive way to reduce the frequnecy of back to back errors
What is retrospective evaluation and quality improvments?
- Root cause analysis (RCA) –> investgation of event that has happened
What is continuous evaluation and quality improvments?
- Continuous quality inprovements (CQI); goal for most healthcare settings (Lean, Six Sigma)
What are some of the unsafe abbreviations that should not be used?
- U, u –> mistaken for 0 or 4 –> wirte out unit
- IU –> mistaken for IV –> write out international unit
- Q.D, QD, q.d (daily); Q.O.D, QOD, q.o.d (every other day) –> mistaken for each other –> write out daily or every other day
- Trailing zeros, or lack of leading zeros
What is one of the ways to avoid look alike, sound alike errors?
- Tall Man Lettering (celeXA vs celeBREX); helps avoid disimilarites in names
What is a high alert medication?
- Those with increased risk of signifiant harm if error occurs
What is Conputerized Physician/Provider Order Entry (CPOE)?
- Direct entry of orders by doctors; alarts can be sent straight to the doctor if needed
What is the one thing that is important to remember about Patient COntrolled Analgesia (PCA) devices?
- Friends and Family of the patient CANNOT administer the PCA doses
PER JOINT COMMISION
What are the steps where a medication error could occur?
- Drug ordered from supplier
- Drug arrives ar the pharmacy and checked into inventroy
- Drug added to stock
- Medication order for patient
- Pharmacist reviews order
- Compounding (if needed)
- Drug delivered/given to patient
- Patient takes drug
What are some of the common hospital acquired infections?
- UTIs from catheters (remove ASAP)
- Bloodstream infections from IV lines and catheters
- Surgeries
- C. Diff
- Pneumonia (most by vents)
When are contact precautions recommended?
- When a patient has MRSA, VRE or C. Diff
When are Droplet precautions recommended?
- Patients with Pertussis, Flu, RSV, andeonvirus, Rhinovirus, Meningitis…
