WK1 Patient Safety I + WK6 Patient Safety II Flashcards
What are the responsibilities of a medication safety leader according to ASHP statement (Reading 1)?
Responsibilities:
* Leadership
* Medication Safety Expertise
* Influencing Practice Change
* Research and Education
What is ADR?
What is ADE?
How are they related?
- An ADR has been defined as harm that results from a medication dose that is “normally used in man.”
- An ADE has been defined as harm associated with any dose of a drug, whether the dose is “normally used in man” or not.
- An ADR, therefore, is a subtype of an ADE (i.e., all ADRs are ADEs, but not vice versa).
- By definition, all ADEs are associated with patient harm, but not all ADEs are caused by an error (meaning they are non-preventable). Significant confusion exists regarding these terms.
What is preventable and non-preventable harm?
“Preventable ADE” is harm caused by the use of a drug as a result of an error (e.g., patient given a normal dose of drug but the drug was contraindicated in this patient). These events warrant examination by the provider to determine why it happened.
“Non-Preventable ADE” is drug-induced harm occurring with appropriate use of medication (e.g., anaphylaxis from penicillin in a patient and the patient had no previous history of an allergic reaction). While these are currently non-preventable, future studies may reveal ways in which they can be prevented.
What is the relationship between medication errors and ADE?
Medication Errors (no harm + near-misses with no harm + preventable harm[ADE])
ADE (preventable harm + non-preventable harm[ADR])
What are the categories of Drug-related Problems? (4 cats)
IASE – Indication, adherence, safety, efficacy
Indication: Drug use without indication, Untreated indication
Adherence: Patient’s refusal to take meds
Safety: Side effects, Drug interactions, Absence of appropriate monitoring
Efficacy: Subtherapeutic dosage regimen
Early detection + early intervention = harm prevention / reduction
Medication safety (zero harm) – basic care
What is Medication safety?
- Free from unnecessary harm / potential harm (med use)
- Free from accidental injuries (med therapy)
- Actions undertaken by individuals or organizations to protect patients from being harmed
- Reduction and mitigation of unsafe acts
- Use of best practices (commercial or professional procedures that are accepted or prescribed as being correct or most effective.)
List the Medication Management and Use.
Organization, Management and Governance
- Selection and procurement
- Storage and labelling
- Prescribing and transcribing
- Preparing and dispensing
- Administration
- Monitoring
Others:
- High-alert Medications
- Look-alike-sound-alike medications (LASA)
- Research Drugs
- Sample Drugs
What are the 3 types of interactions in system thinking?
- System-system interactions
- System-human interactions
a. Healthcare staff use the system - Human-human interactions
a. Healthcare staffs interact with one another
What are the barriers in the swiss cheese model?
- Organisational factors
- Unsafe supervision
- Preconditions of unsafe acts
- Unsafe acts
What are the organisational factors?
- Organizational influences
a. Organizational culture, organizational process, resource management
Culture:
* Adverse events are concealed, lessons learned from mistakes are not shared throughout the organization
* Proactive safety initiatives receive minimal support
* Revenue generation supersedes safety, limited recognition/rewards for safety performance or reporting hazards
Resource Management:
* Poor practices associated with recruiting/retaining personnel
* Limited acquisition of necessary equipment/technology
* Budgetary constraints, excessive cost cutting
Operational Process (planning):
* Lack of leadership engagement
* Conflicting/ambiguous policies
* Unrealistic objectives
Organizing, like planning, must be a carefully worked out and applied process. This process involves determining what work is needed to accomplish the goal, assigning those tasks to individuals, and arranging those individuals in a decision‐making framework (organizational structure).
What are the unsafe supervision factors?
- Unsafe Supervision
a. Inadequate supervision, planned inappropriate operations, failure to correct known problem, supervisory violation
Inadequate Supervision:
* Failure to provide adequate guidance
* Lack of oversight
* Failure to provide appropriate training
Planned inappropriate operations:
* Inadequate staffing/scheduling
* Inadequate workload assignment
Failure to correct known problems:
* Not enforcing the rules, failure to resolve staff conflicts
* Failure to maintain/repair equipment, failure to review/revise policies
Supervisory Violations:
* Authorizing non-compliance, instructing staff to circumvent procedures
* Intentionally breaking the rules
What are the preconditions of unsafe acts?
- Preconditions
a. Situational factors – physical environment, tools/technology
b. Condition of operators – mental states, physiological states, physical/mental limitations
c. Personnel factors – communications, coordination and planning, fitness for duty
Individual Factors:
- Not paying attention, being confused, overconfident, bored, frustrated
- Lacking knowledge or abilities
- Illness, dehydration, fatigue, lacking physical ability to complete a task
- Poor dietary/health practices prior to work
Situational Factors:
- Inadequate design of tools/ technology used (confusing, inflexible, cumbersome)
- Poorly maintained, malfunctioning or outdated equipment
- Suboptimal physical environment: cluttered, poor lighting, poor temperature, poor layout/location of equipment/supplies
Team Factors:
- Poor communication – failure to provide/request information, failure to confirm information
- Poor coordination – failure to plan, prepare, conduct briefing. Failure to ensure role clarity, failure to support team members in completing tasks
What are the unsafe acts? (HFACS framework)
- Unsafe Acts
a. Errors – decision errors, skill-based errors, perceptual errors
b. Routine violations, exceptional violations
Errors:
* Disregarding relevant cues, focusing on irrelevant information
* Forgetting to complete a task, or a step within a task
* Using an improper technique
* Misjudging height/distance, misinterpreting numbers, text or auditory information
Violations:
* Taking short-cuts or skipping steps
* Disabling alarms/removing safety guards
* Ignoring instructions
* Performing activities without license/credentials
* Excessive risk taking
What is the difference between active and latent failures in the swiss cheese model?
- Active failures are those errors which traditionally have been described as human error - driver error and pilot error being typical examples.
- Latent failures – these are decisions and actions that dormant in an organisation for some time until revealed by active failures.
What are the ways to implement new strategies to reduce errors?
- Proactive – take preventive actions in advance
- Reactive – in response to what has happened
- On-going – continuous monitoring of priorities
