Module 4 Flashcards
Scope of the safety problem:
- Safety is an implied minimum standard in providing health care. Yet many are harmed as a result of medical error.
- Research in the area of medication safety & error
prevention has identified some serious concerns for patients & care providers. - As health care delivery systems become more complex, it is evident that the opportunities for error abounds.
▪ The costs of medication-related morbidity & mortality are high.
▪ Many medication errors are preventable, and physicians, nurses, pharmacists can play a vital role in diminishing medication errors.
▪ The medication use process is highly complex, problem-prone, and requires a systematic approach for improvement. - Additional studies frame the issue of medication-related errors in other settings by identifying errors in prescribing and dispensing of prescriptions in an outpatient environment.
- One study found that between 3% and 11% of hospital admissions were attributable to ADEs.
- Errors reoccur despite the best educational and planning efforts.
- To understand what is or is not known about medication-related adverse events, common definitions must be established and understood.
is a complex process involving multiple organizations and professions from various disciplines combined with a
working knowledge of medications, access to accurate and complete patient information and integration of interrelated decisions over a period of time.
Appropriate medication use
have traditionally operated under the assumption that if care providers are well educated and follow well-developed policies, procedures, or guidelines, errors will not happen.
Health care systems
must come to a common understanding regarding medication errors, reporting requirements, and risks to capture and act upon error potential within their own medication use systems.
Organizations
2 types of ADEs:
(1) those caused by errors
(2) those that occur despite proper usage of a medication.
If an ADE is caused by an error, it is by definition,
preventable.
Nonpreventable ADE (injury, but no error)
Adverse drug reactions
Preventable ADE
An injury due to an error in the use of a drug (including failure to use).
a serious medication error—one that has the potential to cause an ADE, but did not, either by luck (e.g, the patient was not allergic to the drug despite a note in the record stating so) or because it was intercepted
Potential Adverse Drug Event (PADE):
an ADR does not result from an error.
Adverse Drug Reaction (ADR)
Understanding the error:
▪ Medication errors are considered preventable while adverse drug reactions are generally are not.
▪ If an error occurs, but is intercepted by someone in the process, it might not result in an adverse event. These potential adverse events are often referred to as near misses.
▪ Capturing information regarding near misses could yield vital information regarding system performance.
▪ Increased patient complexity and decreased numbers of health care staff contribute to potential error.
- A ________ is demanded in health care.
zero error standard
IOM’s Chasm offers four recommendations for a tiered strategy:
▪ Establish a national focus on patient safety
▪ Identify and learn from errors
▪ Raise standards and expectations for improvement in safety
▪ Create safety systems inside health care organizations
is based on systems theory and the work of Deming, Senge, Wheatley, and others who applied systems thinking
to concepts of organizational development, improvement, and leadership.
microsystems concept
defined as small, organized groups of providers and staff caring for defined populations of patients
Microsystems
Targeting Medication Safety at the Microsystem level:
- Focus on the microsystem offers the potential for greater
standardization of common activities. - An increased use and analysis of information and medical evidence
- Constant measurement and feedback of data.
