Module 3 ch 2 Flashcards
Medication Error
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.
Adverse drug event
An injury resulting from medical intervention related to a drug
Preventable adverse drug event
An ADE that results form a medication error that reaches the patient and causes any degree of harm
Potential adverse drug event
Medication errors that do not harm (either by chance or because they were identified before reaching the patient)
Medication Use process
-Ordering/Prescribing
-Transcribing
-Preparation/Compounding and Dispensing
-Administration
5 rights of Medication Administration
-Right Drug, Dose, Patient, Route, Time
Ordering and Prescribing Errors
- Wrong patient, drug, time, dose, dosage form
- omission
- Incomplete or unclear orders
- Patient Allergy
Computerized Physician Order Entry
-Eliminates the risk of incomplete or unwritten orders that may be misinterpreted
-Algorithms and prompts that guide the ordering provided to select the appropriate drug, dose and frequency
Preprinted order forms
Standardized forms will already contain many elements of an appropriate order
When taking verbal or telephone orders
- Transcribe, read back and confirm
- Follow these steps: do not read back, then transcribe
Preventing Errors
- Tall man lettering
- Ensure appropriate use of decimals and zeros
(0.025, 25) - Medication reconciliation during transitions of care
- If there is any doubt about an order, confirm with prescriber
Medication reconciliation
- Changes often occur when patients transition from one level of care to another
- The process of reviewing the medication list against medical records
AD, AS, AU
confused with OD, OS, or OU
CC
Cubic centimeters
Use mililiters
D/C
Discharge or discontinue
HS
Half Strength
IU
International Unit
MG
micrograms
MS, MSO4, MgSO4
For morphine sulfate or magnesium sulfate
Q.D
every day
Q.O.D
every other day
SC or SQ
Subcutaneous
T.I.W
Three times per week
U
units
Preparation, compounding and dispensing errors
- Wrong dose, volume, base solution or diluent, drug, concentration
- Preparations made for incorrect route, wrong patient
Preventing Prep, compounding and dispensing errors
- Independent double-check of all prepared or compounded items
- Limit preparation and compounding outside of the pharmacy department
- Use barcode scan system for product selection
- Use of unit dose or ready to administer packaging
- Follow USP guidance on preparation of sterile or nonsterile compounds
Preventing prep, compounding, or dispensing errors
- Prepare drugs only in packaging that should only be used for the intended route of administration
- Limit overrides of automated dispensing cabinets (ADCs)
- Segregate look- alike sound- alike drugs in the inventory
Admin Errors
- Wrong drug, patient, dosage, dosage form, time, route
- Failure to follow special instructions
- Incorrect infusion rate
Preventing admin errors
-Appropriate labeling
-Pharmacist-to-patient counseling
-Independent double-checks at the bedside for high-alert medications in the acute care setting
-bar code assisted medication administration
-use of smart infusion pumps
quality assurance
factors that influence the quality of medications, pharmacy services, and the medication use process
Continous Quality improvement
A philosophy or formal process in which the specific outcomes are defined, measured and improved over time through systematic improvement efforts
Use of data in the QIP
- May range from one-off quality review to a formal, long term data analysis plan of defined outcomes
Sources
Patient Chart
