T3: Med Safety ADRs/Reporting

Question 1

What is a medication error?

Answer 1

Any preventable event that may cause or lead to inappropriate medication use or patient harm

Question 2

What is and ADR?

Answer 2

Any expected negative outcome inherent to the action of the drug and not always preventable

Question 3

What is an adverse drug event?

Answer 3

Any injury caused by medication

Question 4

What are the common types of medication errors?

Answer 4

1. Prescribing/ordering errors
2. Dispensing errors
3. Administration errors

Question 5

What is the primary problem of admin errors?

Answer 5

Communication

Question 6

How much of all errors are from prescribing/ordering?

Answer 6

50%

Question 7

How much of liability claims are from wrong drug and dose errors?

Answer 7

75%

Question 8

What are the common causes of pharmacist errors?

Answer 8

1. Workload
2. LASA
3. Interruptions
4. Illegible handwriting
5. Lack of support staff
6. Insufficient time to counsel patients

Question 9

What are examples of LASA drugs?

Answer 9

1. Zyrtec and Zyprexa
2. Zyrtec and Zantac
3. Celexa and Celebrex
4. Hydralaxzine and Hydroxyzine

Question 10

How are are Zyrtec and Zyprexa similar?

Answer 10

1. Both white
2. Single daily dose
3. Similar dose range

Question 11

How are zyrtec and zantac similar?

Answer 11

1. Both liquids in amber bottles
2. 5mg/mL vs 15mg/mL

Question 12

How do we create a culture of safety?

Answer 12

1. Start at the highest level (if management doesn’t view safety as priority, no one else will)
2. Blame processes, not people
3. View errors as opportunities to improve systems
4. Praise reporting (great catches, near misses, and errors)

Question 13

What is the important question to answer when an med error occurs?

Answer 13

What went wrong?

Question 14

What is the number for poison control?

Answer 14

800-222-1222

Question 15

Describe safe medication practices?

Answer 15

1. Be proactive
2. Minimize distractions
3. Store drugs properly
4. Thoroughly check all prescriptions
5. Provide patient counseling
6. Repeat and verify phone prescriptions
7. Develop positive ways of managing stress
8. Organize the workplace and develop routines
9. Watch zeros and abbreviations
   10/ Clarify any uncertainties or doubt

Question 16

How do we be proactive in safe med practices?

Answer 16

1. Create a culture of safety
2. Report great catches and near misses

Question 17

How should we provide patient counseling for safe med practices?

Answer 17

1. Show and tell method
2. What did you doctor tell you this medication was for?
   counseling

Question 18

How should we repeat and verify phone prescriptions for safe med practices?

Answer 18

Repeat back each piece of information and place a check mark next to that information

Question 19

How should we organize the workplace for safe med practices?

Answer 19

Understanding the space, environment, and workflow

Question 20

How should we clarify doubts for safe med practices?

Answer 20

Don’t guess

Question 21

What institutions do we report med errors?

Answer 21

1. ISMP (Institute for Safe Medication Practices)
2. FDA MedWatch
3. VAERS (Vaccine Adverse Event Reporting System)

Question 22

Where do we report med errors?

Answer 22

ISMP (Institute for safe medication practices)

Question 23

What is FDA MedWatch?

Answer 23

Online voluntary reporting health professionals, consumers, and patients

Question 24

What do we report to the FDA MedWatch?1

Answer 24

1. Unexpected side effects or adverse events
2. Product quality problems
3. Product/use medications errors that can be prevented
4. Therapeutic failures

Question 25

Where should be report a vaccine ADR?

Answer 25

VAERS: Vaccine adverse event reporting systems

Question 26

Where should we report errors and ADRs?

Answer 26

FDA Medwatch

Question 27

What do we report to the VAERS?

Answer 27

1. Anyone can submit reports
2. Healthcare professionals are encouraged to report administration errors and any adverse event that occurs after administration whether or not it is clearly vaccine related.

Question 28

What are healthcare professional required by law to report?

Answer 28

1. Any adverse event listed in the VAERS Table of Reportable Events Following Vaccination
2. Any adverse event listed by the manufacturer as a contraindication to further doses

Question 29

What is a great catch?

Answer 29

Recognition of any unsafe condition that could lead to patient harm or injury

Question 30

What is a near miss?

Answer 30

An act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation

Question 31

What are the risk reduction strategies?

Answer 31

1. Understand the causes of errors
2. Be sure actions are comprehensive
3. Assess the effectiveness of strategies

Question 32

How do we understand the causes of errors?

Answer 32

1. Root cause analysis
2. Failure mode and effective analysis
3. Self-assessment tool

Question 33

How can we be sure actions are comprehensive?

Answer 33

1. Impact as many steps of the process as possible
2. Layer strategies
3. Choose sustainable strategies

Question 34

How do we assess the effectiveness of strategies?

Answer 34

1. Collect and share data
2. Establish outcome
3. Process measures

Question 35

What is the poison prevention packaging act of 1970?

Answer 35

1. Requires the Rx med, OTC, hazardous material, and other household products be packaged with child-resistant packaging
2. Every Rx gets a safety cap

Question 36

How much of dispensing errors are caught during patient counseling?

Answer 36

83%

Question 37

Where do you report med errors (voluntary practitioner reporting)?

Answer 37

MERP

Question 38

Where do you report vaccine errors?

Answer 38

VERP

Question 39

Where do you report consumer med errors?

Answer 39

C-MERP