safety Flashcards
Types of error
- Dose omission
a. The failure to administer an ordered dose to a patient before the next scheduled dose, it any. This excludes patients who refuse to take a medication or a decision not to administer. - Improper dose
a. Resulting in overdose/underdose/extra dose - Wrong strength/concentration
- Wrong drug
- Wrong dosage form
- Wrong technique
a. Includes inappropriate crushign of tablets. - Wrong route of administration
- Wrong rate
a. Too fast/slow - Wrong duration
- Wrong time
a. Administration outside a predefined time interval from its scheduled administration time, as defined by each health care facility - Wrong patient
- Monitoring error
a. Contraindication
b. DDI-2
c. DFI
d. Documented allergy
e. Clinical (eg glucose, prothrombin, BP) - Deteriorated Drug error
a. Dispensing drug that has expired - Others
Types of patient outcomes
A. No error, but circumstances/events that have the capacity to cause error
B. Error caught before med reached patient
C. Error reached patient; no harm
D. Increased monitoring, no harm
E. Temporary harm requiring intervention
F. Temporary harm requiring hospitalization
G. Permanent harm
H. Near death
I. Death
medication use process
prescribing –> prep & dispensing –> adminstration –> monitoring –> repeat
how can prescribing go wrong
inadequate knowledge about drug indication and contraindication
individual factors (allergy, comorbid etc)
wrong
- pt
- dose
- frequency
- drug
- route
- time
inadequate communication (written/verbal)
dosumentation (illegeible, incomplete, ambiguous
math error
incorrect data entry
how can dispensing go wrong
poor inventory control (exp drug)
labelling / packaging mixed up
transcription error
failure to check DDI, pt factor etc
documentation (illegeible, incomplete, ambiguous)
math error
miscommunication
how can drug administration go wrong
wrong
- drug
- route
- time
- dose
- patient
forget give
documentaion error
how can monitoring go wrong
lack of monitoring adr
drug not ceased when not working or course completed
drug ceased before course completed
drug level not measure / followed up
communication failure
Why do errors occur?
1) Patient factors
- Multi Ds / communication prob / age
2) Medication/technology design factors
- Poor drug manufacturing/distribution practices (marketing stuff, eg name and packaging)
- Complex or poorly design technology
3) Staff/human factors
- Communication/knowledge/fatigue/distraction/violation of SOPs
4) System / workplace factors
- IT/environment/training /manpower
latent errors or system failure pose the greatest threat to safety in a complex system because they lead to operator errors
.
they are failure built into the system and present long before the active error
latent errors are difficult for the people working in the system to see since they may be hidden in computers or layers of management and people become accustomed to working around the problem
latent errors or system failure pose the greatest threat to safety in a complex system because they lead to operator errors
.
they are failure built into the system and present long before the active error
latent errors are difficult for the people working in the system to see since they may be hidden in computers or layers of management and people become accustomed to working around the problem
Root cause analysis is a systematic approach to understanding the causes of an adverse event and identifying system flaws (ie. latent error) that can be corrected to prevent the error from happening again
focusing on these causes and vulnerabilities is a much more effective way to improve quality and safety than simply blaming the individual who made a mistake
focusing on system causes, rather than blame is the central feature of root cause analysis. this is called a systems approach to error
focusing on systems causes means analyzing all the factors that contributed to the error not just the error itself.
Root cause analysis is a systematic approach to understanding the causes of an adverse event and identifying system flaws (ie. latent error) that can be corrected to prevent the error from happening again
focusing on these causes and vulnerabilities is a much more effective way to improve quality and safety than simply blaming the individual who made a mistake
focusing on system causes, rather than blame is the central feature of root cause analysis. this is called a systems approach to error
focusing on systems causes means analyzing all the factors that contributed to the error not just the error itself.
RCA is usually conducted by _____ people.
the team shuld be _______ and should include individuals at all level of the organisation who are close to and have fundamental knowledge of the issues and processes involved in the indident.
RCA is usually conducted by _4-6____ people.
the team shuld be __interprofessional_____ and should include individuals at all level of the organisation who are close to and have fundamental knowledge of the issues and processes involved in the indident.
simplified RCA 3 questions
1) what happened? Describe the key steps
2) what went wrong and why? identify the failed processes
3) what to do to prevent incident recurrence? suggest risk reduction strategies and their implementation
steps to reduce error
1) Reduce Reliance on memory
2) Simplify
3) Standardise
4) Use forcing and constraints function
5) Use protocols and checklist wisely
6) Improve access to information
7) Decrease reliance on vigilance
8) Reduce handoffs
9) Differentiate: eliminate look-alikes and sound-alikes
10) Automate carefully
high alert medication
soecial safe guard
drugs that bear a heightened risk of causing significant patient harm when used in error
mistakes may or may not be more common
consequences of an error are clearly more devastating
safeguard:
- improve access to information about these drugs
- limit access to high alert medication
- use auxiliary labels and automated alerts
- standardize ordering, storage, preparation and administration
- employ automated or independent double checks when necessary,
ISMP key recommendtion for safe electroniccomunication of medication order`
use generic name
avoid including salt of chemical
differentiate generic name from brand name
standardise inclusion of suffixes
sstandardise use of mnemonic or short names
standardise fonts and colours
