medicine and patient safety Flashcards
what is the medication-use process
1- prescribe ( doc nurse dietitian pharmacist )
2- transcribe ( doc nurse pharmacist dietitian )
3- dispensing ( pharmacist and pharmacy tech )
4- administrating ( nurse doc pharmacists and patient as insulin/inhalers )
5- monitoring ( doc nurse pharmasists )
——- is the preventable event that cause or lead inappropriate use or patient harm while medication is in the control of the healthcare professional, patient or consumer
medication error
examples of medication error:
1- error in selection of prescribed drug
2- ordering incorrect drug from the pharmacy
3- error in dispensing the drug
4- incorrect instructions to patient ab using the drug
5- monitoring surveillance steps are skipped or incorrect
true or false:
prescribing medicine is the most common intervention ( for good or bad ) made to improve the health of patient
true or false:
almost all errors are intercepted by pharmacist before they could affect the patient
true , true
—- an in-depth investigation into causes of prescribing errors
Equip
prescribing error examples
- incorrect dosing
- drug interaction with another drug taken by the patient
- illegible handwriting
- electronic prescribing errors ( as: wrong medication , wrong strength )
risk management - to take the right medicine :
1- take the full drug history aka:
- ask for current prescription medicines ( ask about other forms of the medicine as inhalers )
- record about ADRs including allergies
- ask ab non-prescribed medication as herbal and illicit drugs
2- choose the most appropriate drug aka:
- use resources and guidelines and take advice
Risk management for prescription include :
1- right medication
2- legibility aka hand writing
3- numerals as:
- avoid unnecessary decimal point 2mg not 2.0mg
- always use preceding zero if decimal point is necessary as: 0.5 not .5
- qaunaties of 1g must be written as 1g
- quantities less than 1g must be written in milligrams as 500mg not 0.5mg
4- abbreviations aka a short cut to medication errors
SALAD errors is an example of —-
dispensing and admisntration error (aka medicine look-alike )
strategies to reduce salad errors
- write the full name of the drug and never abbreviate
- include indication for a medication to add clarity to the prescription
- specify the exact dose and never use as directed
- consider tall man lettering as : OxyCONTIN , OxyNORM
- avoid giving/accepting verbal medication orders/prescription
true or false:
pharmacist should avoid stocking medication w/ packaging prone to SALAD errors “purchase safety policy”
true
Reason’s model of accident causation states :
latent condition ( organisational process and management decisions ) —> error producing conditions ( environmental , team , person , task factors that affect performance ) —> active failure as errors including slips/lapses/mistakes and violation as ignoring the rules —> accident
error reduction strategies include:
( from easies and human reliable to hardest and most effect system reliable )
- suggestion to be more careful
- available info
- educational programs
- rules and polices
- warning, reminders,checlist , alerts
- redundancies
- standrization and protocol
- automation and computerisation
- barrier and fail-safes
- forcing function
prescribing safety assesement ( PSA )
1- prescribing
2- prescription review
3- planning management
4- providing info
5- calculation skills
6- adverse drug reactions
7- drug monitoring
8- data interpretation
true or false:
the majority of the medication errors occur as a result of poor prescribing , emphasising the need to improve prescribing skills
true
true or false:
supportive safety culture should be adopted to improve the rate of reporting of medication errors , allowing further investigation of these important pf preventable harm
true
