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PHAY0085 > Medicines Safety > Flashcards

Medicines Safety Flashcards

1
Q

Which sectors of healthcare are involved with local shared care arrangements?

A

General practice
Hospital
Community pharmacy
Patient and carers

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2
Q

How would an error that is high urgency, high importance be managed?

A

Contact relevant individual directly
Consider documenting in medical notes

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3
Q

How would an error that is low urgency, high importance be managed?

A

Ideal to contact relevant individual but can be documented in patient notes

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4
Q

How would an error that is high urgency, low importance be managed?

A

Ideal to contact relevant individual but can also leave written communication on ward or be documented in patient notes

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5
Q

How would an error that is low urgency, low importance be managed?

A

Leaving written communication for doctor on ward or in medical notes

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6
Q

What is iatrogenic harm?

A

Harm caused by healthcare - not all medication errors result in harm but there is an overlap

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7
Q

What is medication error?

A

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of healthcare professional, patient or consumer

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8
Q

What are the four principles of the RPS medicines optimisation?

A
  • Undestand patient experience
  • Make evidence based choices
    -ENSURE MEDICINE USE IS AS SAFE AS POSSIBLE
  • Make medicines optimisation part of routine practice
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9
Q

What is MSO?

A

Medicine Safety Officer usually a pharmacist present in organisations who focuses on local reporting, feeding into the NRLS and getting safety alerts from a central system

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10
Q

What are the four domains in the WHO:medication without harm?

A

Patient and public
medicines
healthcare professionals
systems and practices

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11
Q

What are the THREE early priority focus areas part of the WHO: medication without harm

A

high risk patients and situations
polypharmacy
transitions of care
(also updating med safety curriculum)

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12
Q

At what points in hospital practice can harm occur? (6)

A

admission
prescribing during the inpatient stay
dispensing medication
administering medication
monitoring medication
discharge from hospital

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13
Q

When may errors occur during admission to hospital?

A

Discrepancies in drug histories due to:
- errors in determining medication history
- transcribing details of this into clinical record
- prescribing medication onto drug chart

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14
Q

How may a drug history be collected?

A

USE AT LEAST TWO SOURCES

  • ask patient
    -PODs
    -phone GP
    -recent admission drug charts
    -SCR
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15
Q

Why are there varying rates of published prescribing errors across the UK? (5)

A
  • different methods of reporting
  • different ideas of what counts as an error
  • differences between hospitals, settings and groups of prescribers
  • differences in patient populations (low vs high risk)
  • changes over time (introduction of new interventions to make prescribing safer)
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16
Q

How may prescribing errors be reduced?

A

Educational interventions
Feedback on errors
Non-medical prescribers - specificity/scope of prescribing may make them less likely to make errors
Electronic prescribers

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17
Q

How may errors be identified and rectified?

A
  • Ward pharmacy services : screening medication orders
  • Pharmacists check drug chart
  • Clear, legal, clinically appropriate
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18
Q

Where are some high risk areas where they may be medication errors when prescribing? (8)

A

Medication history
Transcription of new drug chart
Allergies
Dosing in renal/hepatic failure
Drugs with low therapeutic index
Brand vs generic names
Duplication
Dose calculations

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19
Q

What medications may be used in hospitals? (4)

A

PODs
Ward stock
Dispensed as inpatient supply
Dispensed for discharge

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20
Q

Advantages (4) and disadvantages of PODs.

A
  • Assists with med history
  • Continuing of meds pt is familiar with
  • Less risk of dose omission as there is already a supply on ward
  • less waste
  • Needs to meet criteria : identifiable, in date, labelled with patient name, in good condition
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21
Q

Risk benefit assessment when considering ward stock.,

A

Costly drugs
Dangerous drugs
Rarely used drugs
Drugs for which patient name needs to be recorded
Drugs for emergency use

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22
Q

What is the difference in labelling for a drug dispensed for discharge and in-patient supply.

A

In-patient supply has no directions on label as nurse doses based off drug chart

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23
Q

Where can dispensing errors arise in hospital?

A

LASA drugs
Errors in patient name
Usually identified and rectified after the final check

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24
Q

Medication administration errors?

A

IV higher compared non-IV: More complex to prepare and administer
Errors when given too quickly

Medication unavailable at point of administration - dose is missed
Wrong drug, wrong formulation, wrong dose

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25
What is the role of the pharmacist in the prevention of medication administration errors?
Educating nursing staff on common errors and how to avoid Clarify prescriptions if unclear Medication supply and labelling Accompany on drug rounds Use of technology such as barcode medication administration
26
Why is monitoring required after administration of medication in hospital
Efficacy Safety and toxicity Taking appropriate action based on results
27
Where can problems occur with monitoring?
Failure to monitor Failure to monitor correctly or at the right time Failure to check results Failure to act appropriately after checking results
28
What is important when patients are discharged from hospital?
Informing the patient and GP about any changes to their medication at discharge and the appropriate action to take following this (eg, review and restarrt)
29
What is the role of the hospital pharmacist at discharge?
- Check TTA against inpatient chart - Ensure medication reconciliation details are recorded: stopped started changed and why - What medications needs to be supplied
30
How can errors be defined?
By standards By consensus of a panel BY science By a user defined definition
31
How can errors be detected?
Incident reporting systems Observation Case note review Pharmacist review of prescription Except for observation all are reliant on data quality
32
What are the advantages and disadvantages of using observation to detects errors?
- Accurate - Time consuming and labour intensive -Covert: ethical issues - Overt: effect of knowing they are being observed
33
Where can errors arise in primary care?
Prescribing Presentation - not actually given to pharmacy Dispensing Adherence - MOST error is here Errors lead to effects such as ineffective medication or drug related admission
34
Why are older people more at risk of GP prescribing errors?
Polypharmacy Interactions Comorbidities
35
What is CHUMS?
Care Home Use of Medicines - an observational study that aimed to identify frequency and cause and severity medication errors in care homes and suggest solutions
36
What were some consequences of medication errors identified by CHUMS?
Harm Loss of quality of life and dignity Time taken to resolve Stress for staff and residents
37
What were some causes of prescribing and monitoring errors within care homes?
GPs prescribing on papers - not accessot previous notes, meds etc Failure to update notes when returned to practice GP unfamiliar with residents Residents and staff Poor communication Monitoring errors issue with GP systems and IT to flag patients Difficult getting bloods from older patients
38
What are some causes of medicine administration errors in care homes? (13)
Use of MDS Difficult patients End of shift - staff tired Inaccurate medicine administration record Work environment Staffing problems Poor design of medicines trolleys Distractions Lack of knowledge about meds (how to administer, taking with food) Failure to anticipate needs - out of stock Lack of policies Communication between home/GP and pharmacy Staff retention
39
Why may use of MDS lead to medication errors?
Day to day changes in doses Some medication not appropriate for MDS - two systems in parallel could be complex
40
What are some examples of technology used in hospitals?
Electronic prescribing Barcode identification Smart pump for infusion Ward based dispensing cabinets Dispensing robots
41
How can we evaluate IT use in hospitals?
- How do properties of object vary over time and how do people use it - Formative and summative evaluation - Context - e.g. works differently in different settings - Benefits to different stakeholders
42
Advantages of technology
Good for repetitive tasks Follows rules Forcing functions - can't proceed until all fields completed More legible compared to handwrititng Audit trail Reminders and alerts Supporting formularies and protocols
43
Disadvantages of technology
Inflexible New error types e.g. clicking the wrong thing in a selection menu or assuming the computer must be right New work processes and developement of workarounds Alert overload may mean key alerts are dismissed
44
How to maximise reduction of old errors and minimise the amount of new errors introduced when using technology in healthcare?
Look at how system is set up, how people interact with it and the appropriate training to use
45
What are the three factors in Reason's Causation Model?
LATENT CONDITIONS ERROR PRODUCING CONDITIONS ACTIVE FAILURES
46
What are latent conditions and what do they lead to?
Organisational conditions Management decisions Organisational processes Lead to error producing conditions which lead to active failures
47
Why is only looking at active failures unhelpful?
Supports blame culture Doesn't consider latent conditions and error producing conditions that can lead to active failures and holes in defences
48
What are the types of active failures? (4)
Slips and lapses Mistakes Violations
49
What are the TWO planned failures?
Mistakes and violations
50
What is a mistake?
Mistakes are rule or knowledge based when you do something you think is correct but it isn't
51
What is a violation?
Intentional deviation from rules or good practice because you believe it doesn't matter or wont cause harm
52
What are the three types of violations?
Routine : normal ways to cut corners, opitmise efficiency and workaround Exceptional violations - rarer but not always with bad intentions Sabotage - deliberately nefarious intentions
53
What are the two types of execution failures? (UNINTENDED)
Having the correct plan but not following it correctly Slips - attention failures Lapses- memory failures
54
What are some error producing conditions?
Patient factors - complex cases, communication issues Task factors Individual factors Team factors Working conditions Organisational factors (rotas, roles, staffing) Institutional context (rules, regulations) Technology factors
55
What are latent conditions?
Organisational or culture conditions - action and decisions made by those away from the 'front lines' - adverse consequences only emergy when other system defences are breached
56
What is an example of a latent condition?
Education policy Training structure Legal structure
57
What are the types of incident reporting systems?
Local Organisation National
58
What are local error reporting systems?
Within the pharmacy - near miss logs
59
What are organisational error reporting systems?
Those within a hospital trust or a chain of pharmacies - may use a local risk management system such as Datix which looks at hazards security risks etc MSO Self-reporting most errors missed If error doesn't reach patient e.g. due to pharmacist intervention then not recorded
60
What is the NRLS?
National error reporting system - National Reporting and Learning System used to record all types of safety incident incl. medication Safety incidents, near misses and good practice examples Mostly incidents from secondary care
61
What is a key role of NRLS?
Creating national patient safety alerts and other guidance such as insulin passport or valproate for women of child bearing age
62
What are some quality improvement approaches and tools?
Lean Six Sigma Statistical Process Control Plan, Do, Study, Act (PDSA)
63
Outline the Plan, Do, Study, Act (PDSA)
Plan - What do we need to improve? Do - Make changes on a small scale and let it settle in Study - Measure impact Act - Continue with change? Modify? Stop and find new idea??
64
What are the key elements of quality improvement?
Data - measurable in a meaningful way Longitudinal Understanding the process - What do you think happens from looking at SOP vs what actually happens
65
What is the most common risk assessment used in healthcare?
Failure mode and effects analysis (FMEA)
66
Outline the stages of FMEA?
1. Chose a topic and assemble a multidisciplinary team 2. Map out processes and subprocesses 3. Decide probability, detectability and severity of a failure (1-5 scale) 4. Multiply everything together and look for largest number to prioritise areas
67
What are some disadvantages of FMEA?
Time and meetings Issues with making it work in practive Risk priority number system is not very valid
68
What is important when a perosn has suffered errors/harm?
OPEN DISCLOSURE - take initiative , show respect, promptly apologise Duty of candour - patient MUST be informed if moderate or severe harm
69
What approach should be used when errors occur?
"just culture' or 'fair blame' instead of blame culture or no blame Need to support staff involved with errors
70
How to understand local risks to reduce error?
Incident reports Audits Prospective risk assessment - FMEA Focused data collection
71
What is standardisation?
Standardising treatment plans, processes, systems and communication to reduce error but remember patients are unique so 'standardisation with customisation'
72
What does it mean to treat both patient in error reduction?
Treating the patient in front of you but also seeing the organisation as a sick patient that needs changing
73
What is judicious use of technology?
Avoiding over-reliance
74
How can patients be involved with their own safety?
Informing the management plan by sharing information with clinicians and asking questions about treatment decision monitoring and ensuring safe delivery of treatment Informing systems improvement by providing feedback on care quality
75
What is the role of HCPs in making sure patients are involved in their own safety?
Encourage them to ask questions Avoid defensive approach to queries or concerns
76
What are the two views of safety?
Medical view - avoidance of harm Patient view - " I feel safe'
77
How can a safety culture be maintained ? (4)
communication mutual trust shared perceptions on the importance of safety confidence in efficacy of preventative actions
78
What are the 5 important characteristics to reduce harm in high reliabilty cultures?
Anticipating the unexpected Be preoccupied with failure - aware things can go wrong Be reluctant to simplify - don't make assumptions or take things for granted Be sensitive to the state of your systems - being aware when problems can arise Contain the unexpected Commit to resilience - anticipate errors and how they can be dealth with Defer to expertise
79
What are technical vs non-technical skills?
Technical - related to the role or profession you are in Non technical skills - generic skills not specific to profession Need to be used together to practice safely
80
What are some non technical skills?
Teamwork COmmunication Decision making Situational awareness Stress management
81

PHAY0085 (15 decks)

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