QI Flashcards
What is the failure to complete a planned action as intended, or the use of a wrong plan to achieve an aim?
Medical Error
What is the most common type of medical error?
Medication Error
What are some examples of medication errors?
- Ordering
- Transmission of escripts
- Preparing/Labeling/Administering the medication
Name 7 ways you can reduce medication error
- ID current meds (including OTC/Herbals)
- Keeping allergies up to date
- Neat handwriting
- Avoid abbreviations
- Accurate weight
- No zeros after a number (okay if before- i.e. 0.3 okay, 3.0 not okay)
- Include diagnosis, especially for drugs that sound alike
What is an injury caused by medical management (versus underlying disease or condition)?
Adverse event
What type of error causes harm to the patient?
Adverse event
True or False: Most medical errors don’t lead to an adverse event
True
What is an injury resulting from the use of a drug?
Adverse drug event
True or False: Most adverse drug events don’t result from a medication error
True
*May result from medication error, but most don’t (like an unforeseen drug reaction)
What is a response to a drug which is harmful and unintended?
Adverse drug reaction
True or False: In order for an event to be considered an adverse drug reaction, dosing has to be appropriate for the situation
True
True or False: A side effect is considered an adverse drug reaction
True
What is a specific type of adverse drug reaction mediated by an immune response
Allergic reaction
What is a situation where a medical error places a patient at risk for injury without actually resulting in injury?
Near miss event
Name 2 situations that would be considered to be near miss events
- Intercepted
2. Non-intercepted
What type of error is noted before it gets to the patient?
Intercepted error
For all intents and purposes, it never happened
What is an error that reaches the patient?
Non-intercepted error
True or False: A non-intercepted error may or may not cause injury
True
What describes an actual or potential death or serious injury as a result of medical care?
Sentinel Event
True or False: Sentinel events are the result of medical errors
False- Not all are
The risk for ADE’s is how many times higher in hospitalized children than adults?
3
What is a common cause of dosing error for medications in children?
Compounding adult prepackaged medications for children
What two home factors should you consider for a patient with an adverse drug reaction?
- Guardians who don’t speak English well
2. Using home folk/traditional remedies (interact with a prescribed medication)
Adverse events occur in what % of pediatric hospitalizations?
1%
What % of adverse events in pediatric hospitalizations are preventable?
60%
Why are ADE rates rising?
Possibly increase ability to detect rather than an actual increase in the incidence of these events
What is the estimated cost of medical errors in the US?
37 billion/year
True or False: Medicare/Medicaid are beginning to not reimburse to correct medical errors that increase length of stay
True
Name 4 barriers to reporting medical errors
- Not wanting to be blamed
- Not wanting to appear incompetent
- Not wanting to be the whistleblower
- Fear of litigation
True or False: Randomly auditing charts for medical errors would waste resources and is likely unhelpful
True
What is “triggering”
Smoking gun technique- Example is to audit charts where a sedative reversal agent was used to ID an adverse drug event involving sedatives
What is a trend whose goal is to increase reporting for the common good?
Blameless reporting
What are 3 strategies to help with providers reporting medical errors?
- Blameless reporting
- Immunity (in terms of litigation)
- Counseling/Debriefing services
What are 4 things to remember when disclosing an error to a patient’s family?
- Be totally transparent
- Disclose why it happened
- Explain how it will impact them
- Explain what steps are being taken to prevent such an error from happening again
True or False: Disclosing errors to families has been shown to reduce litigation and decrease settlement amounts
True
True or False: You should apologize to a patients family when disclosing an error?
True
*Movement towards apologies being prevented from use in legal proceedings
What are 2 things institutions are now providing for physicians when medical errors occur?
- Suspending judgement of competence
2. Providing support via debriefing
Name 5 ways that computers help to reduce medication errors
- Eliminate handwriting issues
- Weight-base calculators
- Errors messages with overdose alarms
- Alerts for drug interactions
- Alerts of drug contraindications (based on diagnosis)
Name two provider-based strategies to help reduce medication errors
- Pharmacist on inpatient rounds
2. Request order reviews by pediatric pharmacists
