medicines safety Flashcards
name 6 points in a hospital where medication errors can occur
admission, prescribing, dispensing, administration, monitoring, discharge
why is medicines reconciliation important?
ensures accuracy, prevents errors during transitions of care, maintains continuity
what contributes to errors during admission?
inaccurate drug history, poor reconciliation, reliance on patient memory
what actions can pharmacy professionals take to prevent these errors?
use of dose alerts and clinical decision support systems (CDSS)
medication reconciliation
clear documentation (no “as directed”)
direct communication with prescribers
educating patients
reporting incidents
use of standardised protocols (e.g. MTX only once-weekly).
dose alerts and CDSS (clinical decision support systems).
patient-held records (e.g. RA monitoring booklets).
remove high-risk products (e.g. MTX 10mg tablets where possible).
ensure second checks for high-risk meds (but evidence is limited).
education and training (e.g. opioid stewardship, PPP for valproate).
how does this link with other pharmacy practice teaching?
medicines optimisation principles
role of MSOs and NRLS reporting
medicines reconciliation (NICE/NPSA guidance)
shared care agreements
high-risk medicines protocols
what’s the pharmacist’s role in discharge?
check TTAs, document med changes, ensure patient & GP are informed
why is it important to involve patients in their medication safety?
they can catch discrepancies, understand their meds, and report issues
what is Reason’s Accident Causation Model?
“Swiss cheese” model where system failures align and allow an error to pass through every layer of defence
what are the three layers of error in Reason’s model?
latent conditions → error-producing conditions → active failures
define active failures in Reason’s model
slips & lapses: right plan, poorly executed
rule-based mistakes: wrong rule applied
knowledge-based mistakes: no clear rule, unfamiliar situation
what are active failures?
slips, lapses, mistakes, and violations made by front-line staff
give examples of mistakes
wrong rule used (rule-based), lack of knowledge (knowledge-based)
what’s the difference between a slip and a lapse?
slip = attention error
lapse = memory error
give real-life examples of these failures
rule-based: pharmacist assumes weekly med is daily
knowledge-based: unfamiliar side effect misjudged as minor
slip: nurse draws wrong drug due to look-alike packaging
how does Reason’s model explain the methotrexate case?
active: wrong dose prescribed.
error-producing: poor med rec, comms failure.
latent: no alert in system, shared care issues
how can Reason’s model help understand medication errors?
identifies multiple system weaknesses (e.g. MTX case)
emphasises layers of defence: prescribers, pharmacists, patients
encourages system-wide fixes, not individual blame
how can Reason’s model guide error prevention?
helps identify deeper system flaws, not just individual blame
what are the three levels of incident reporting?
local (within pharmacy), organisational (e.g. trust), national (e.g. NRLS)
what is the NRLS and what is it for?
the National Reporting and Learning System collects incident reports to support system learning and safety improvements
what’s a near miss?
an error that could have caused harm but was caught in time
why might pharmacists underreport incidents?
they view interventions as part of routine, time pressure, lack of feedback
what is an MSO and their role?
a Medication Safety Officer ensures local incident reporting and learning, feeds into NRLS, and receives alerts via MSOnet
what are key principles of quality improvement?
systems thinking
continuous learning
root cause analysis
PDSA cycles
stakeholder involvement
what does PDSA stand for?
plan, do, study, act
