SMP Intro

Question 1

ADE

Answer 1

Injury resulting from medication intervention related to a drug (focus)

Question 2

Potential ADE

Answer 2

Error that has potential to result in at least significant injury (preventable)

Question 3

ADR

Answer 3

• Unexpected, unintended or excessive response to a medication that occurs at doses used in therapy or prophylaxis
• Excludes therapeutic failures, poisoning, drug abuse, and preventable events

Question 4

Sentinel Event

Answer 4

Unexpected occurrence involving death or serious injury

Question 5

Misadventure

Answer 5

Events that are always unexpected but may be too broad (idiosyncratic reactions/ADRs)

Question 6

Error Types

Answer 6

• Depend on intention
• Non-intentional errors: lapses and slips
• Intentional errors: harder to detect, more subtle, more complex that tend to arise from lack of expertise or experience (more of a true mistake than lapse/slip)

Question 7

Slips

Answer 7

Error made while busy and distracted that was simply not noticed (grabbing the wrong drug)

Question 8

Lapse

Answer 8

Error made in familiar environment due to lack of attention to current job at hand (not reconstituting a suspension)

Question 9

National Quality Forum

Answer 9

• Public-private partnership for all portions of healthcare
• Formed to develop a common approach to improve HC quality and system-wide improvements
• Established 34 safe HC practices that should be universally applied
• Most successful practices have been clinical

Question 10

JCAHO

Answer 10

• Now Joint Commission
• Designing processes/standards to assess quality improvement and patient safety
• Established a series of patient safety goals

Question 11

ISMP

Answer 11

Monthly newsletter with good information on contemporary med errors and events

Question 12

VA HC System

Answer 12

• Transformed under Ken Kizer
• Implemented bar coding, electronic medical records, and CPOE
• Example of cultural change

Question 13

Error/ADE Reporting Systems

Answer 13

• FDA MedWatch
• USP MEDMARX
• NCC MERP
• Patient Safety Reporting System (VA)

Central system that collects and analyzes reports across all HC domains is still needed

Question 14

Leadership Traps

Answer 14

• Reacting defensively to safety issues
• Blaming providers/front-end operators
• Withholding the truth
• Focusing on the wrong metrics

Question 15

Appropriate Leadership Behaviors

Answer 15

• Changing culture
• Ownership for patient safety: emphasize learning, develop reporting, regular training, full transparency
• Encouraging imagination

Question 16

Unit Dose Studies

Answer 16

• Conducted by pharmacy profession
• Saw significant reduction in administration/dispensing errors
• In the end, failed to be funded

Question 17

Contributing Factors to Prescribing Errors

Answer 17

• Dosing calculation use
• Multiple zeros
• Dose < 1
• Documentation decimal
• Wide dosage range (levothyroxine)
• Injectables and oral liquids
• Decline in renal/hepatic function
• History of allergy in same class
• Wrong name, form, abbreviation
• Dose calculation errors
• Atypical/critical dosage frequency considerations