Patient safety Flashcards
What are drug related problems?
an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes
What are adverse drug events?
any harm relating to the use of medication
What are medication errors?
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
What are adverse drug reactions?
unpredictable harmful or unpleasant reaction to a drug at a routine dose
What are the 5 steps of medicine getting to a patient?
- Prescribing
- Dispensing
- Administration
- Monitoring
- Transition of care
What are the 5 ‘R’s for medication safety?
Right drug
Right route
Right time
Right dose
Right patient
What are the 3 typical drug monitoring errors?
Inadequate monitoring for side effects
Not stopping the course once completed or drug no helping
Not completing the full course when indicated
What is the person centred apporach to errors?
- This views errors as happening because of the mental processes of individual practitioners
- Therefore, to increase safety we need to focus on making everyone behave the same (e.g. more procedures, naming and shaming, disciplinary action)
What are the 4 problems with the person centred approach?
- Humans are flawed - even with simple tasks we can make mistakes
- Many accidents and mistakes are not ‘blameworthy’
- Important to look at errors in context of systems where they happen
- Can lead to cover-ups as people try to dodge blame and punishment
What is a slip/commission mistake?
Pick a frequently dispensed medicine rather than the medicine you intended to select
What is a slip/omission mistake?
Forget to confirm patient’s details before handing over medicines
What is a rule-based mistake?
Dispensing a common strength of a medicine because that is what is usually prescribed
What is a knowledge-based mistake?
Dispensing modified-release tablets instead of standard tablets (didn’t know there was more than one form of the medicine)
What are the 4 types of violations?
- Routine (signing check box without checking)
- Situational (CD register not filled due to queue)
- Exception (computer breaks so labels hand-written)
- Sabotage (Selling POMs off prescription)
What are the 5 main factors considered to cause mistakes?
- Work environment
- Team
- Individual/staff
- Task
- Patients
What are the two types of risk management tools?
- reactive (root cause analysis)
- proactive (failure mode and effects analysis)
What are the 4 types of reactive tools?
- Pharmacy error logs
- National incident reporting systems
- Never events
- Root cause analysis
What are the 4 key parts of fulfilling duty of candor?
Information about pending investigation
A letter of apology confirming investigation terms of reference
Contact details for updates
Offer to meet patient to discuss findings
What is Root Cause Analysis?
A structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it
What are the 6 steps of RCA?
- Gathering information about an incident
- Mapping the information
- Identifying problems
- Analysing contributory factors
- Determining root causes
- Developing recommendations and implementing solutions.
What is the best method for determining the root causes?
5 ‘whys’
- ask why to each cause to probe deeper until proper casue is revealed
What is the action hierarchy?
- Weaker actions - training + procedures
- Intermediate actions - software modifications
- Stronger actions - engineering controls, changing processes
What is Failure Modes and Effects Analysis (FMEA)?
A systematic method, carried out by teams used to identify and prevent process errors and product problems before they occur
What are the steps of an FMEA?
- Graphically describe the process
- Identify failure modes
- List the causes of the failure modes and catagorise according to Accident Causation Model
- Design interventions
- Identify outcome measures for interventions
- Implement and monitor interventions
What are the 5 strengths of FMEA?
- Proactive
- Detailed & invites people to consider system factors that could cause errors
- Systematic
- Emphasises team involvement
- Ratings can be useful in helping teams identify where to start
What are the 4 weakness of FMEA?
- Ratings are unreliable if not done by someone experienced
- Different teams won’t produce the same analysis
- Very time consuming
- Less guidance on interventions
