Preventing And Managing Medication Errors Flashcards
_______ is a medication reaction in which everything was done right and there was nothing wrong in the process (no gap), but there was an unexpected reaction.
Adverse Drug Reaction (ADR)
_________ is the sum of ADRs + medication variance/errors. It refers to any drug-induced adverse outcome, whether it is a result of an error or not.
Adverse Drug Event (ADE)
________ is an error that does not reach the patient (mistake most likely caught by another practitioner), but is still important to learn from.
Near Miss
True or False: more medication errors occur in the hospital setting than in the outpatient community setting.
False. More medication errors occur in outpatient setting than in inpatient setting.
Studies funded by congress discovered that 17-30% of patients have experienced at least one serious event. Of these events, the largest portion were attributed to ______.
Adverse Drug Events (ADEs)
______ is an event that happens as a result of medication use that is harmful and preventable. So there is a normal process that occurs, but something in the process went wrong. So there is a gap in the defined process.
Medication variance/error
True or False: serious medication errors increase hospital length of stay and hospital costs
True
Preventable ADEs account for _% of national health expenditures in 1996
4%
True or False: errors are rarely due to “faulty people”
True
It is important to create a _________ to show professionals that they will not be penalized for coming forward and reporting an error. It is a key component to a successful medication safety program.
Just culture/ non-punitive environment
What are the 2 types of medication errors?
- System/process errors (ones that are inherent to system error)
- Human errors
What are the 6 steps in the medication use process?
- Procuring
- Prescribing
- Transcribing
- Dispensing
- Administering
- Monitoring
Of the 6 steps in the medication use process, which step is the top source of medication errors?
Prescribing
Of the 6 steps in the medication use process, list the top 2 steps that are the sources of medication errors?
- Prescribing
2. Administration
Which type of error decreased and became almost non existent following the implementation of EMR?
Transcribing errors
True or False: when re-designing medication related processes, out attempts to “fix” one aspect can sometimes lead to unexpected/undesirable consequences in other areas.
True
Looking specifically at prescribing errors, the following 3 types of prescription errors decreased with the implementation of EMR.
Dose, rate, and route of administration
The goal of the pharmacy and pharmacist is to be reactive and _______ to build a safer medication use system.
Proactive
Name two examples that were used in the PowerPoint that taught us to be reactive and proactive.
- Bio-contamination of insulin pens
2. Fungal meningitis outbreak
What does FMEA stand for?
Failure Modes Effect Analysis
________ is a medication safety tool that allows you to talk through the process to identify what possible problems exist and what’re the consequences if a failure occurred and how frequently does this occur. From there, you rank the problems based on severity and frequency of the potential risk.
Failure Modes Effect Analysis (FMEA)
Explain the step by step approach to improve medication safety that FMEA employs.
- Systemically identify all possible failure points
- Study the consequences of those failure points
- Prioritize failures based on:
- how serious their consequences are
- how frequently they may occur
- how easily they can be detected - Take actions to eliminate or reduce failures, starting with the highest-priority ones.
