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PHM 110

Chapter 12

What is a medical order? any circumstance, action, inaction, or decision related to health care that contributes to an unintended health result
What is a medication order? any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer
What is an omission error?** occurs when a prescribed dose is not given. Omission occurs when the next dose is due, but the previous dose was not administered
What is a wrong dose error?** occurs when a dose is either above or below the correct dose by more than 5%
What is a extra dose error?** occurs when a patient receives more doses than were prescribed by the physician
What is a wrong dosage form error?** occurs when the dose formulation given to the patient is not the accepted interpretation of the physician order
What is a wrong time error?** occurs when any drug is given 30 minutes or more before or after it was prescribed, up to the time of the next dose. Occurs more in hospitals and nursing homes. does not include prn order
What is a human failure? occurs at an individual level. Which means its your fault. Like if you pull the wrong drug based off memory
What is technical failure? results from location or equipment. When a machine messes up the medication
What is organizational failure? occurs because of organizational rules, policies, or procedures. Such as preparing a hazardous drug without the proper environmental controls
What is root cause analysis? logical and systematic process used to help identify what, how, and why something happened in order to prevent recurrence
What are the 9 steps of the filling process? receive and review prescription.enter into computer.perform DUR and resolve med issues.generate label.retrieve med.fill or compound pres.pharmacist review and approval.store completed pres.deliver med to patient
What are the 5 rights for patient drug administration and medication error prevention? right drug.right strength.right route.right patient.right time
Who do you report a medication error to? depending on the severity most of the time to the pharmacist. then its taken to the next levels such as joint commission and board of pharmacy
What is a sentinel event? an unexpected occurrence involving death, serious physical or psycological injury, or the potential for such occurrences to happen. Someone most likely gets fired. and the whole pharmacy is investigated
What is ISMP? institute for safe medication practices. nonprofit healthcare agency whose membership is primarily comprised of physicians, pharmacists, and nurses
What is the mission statement of the ISMP? to understand the causes of medication errors and to provide time critical error reduction strategies to the health care community, policy makers and the public
Assumption error error that occurs when an essential piece of info cannot be verified and is guessed or presumed
Capture error error that occurs when focus on a task is diverted elsewhere and therefore the error goes undetected
eMAR electronic medication administration record, used to minimize medication errors
MERP medication error reporting program. USP program designed to allow healthcare professionals to report medication errors directly to the ISMP
MEDMARX internet based program of the USP for use by hospitals and healthcare systems for documenting, tracking, and identifying trends for adverse events and medication errors
MedWatch voluntary program run by FDA for reporting serious adverse events for med. and medical devices; serves as clearinghouse for info on safety alerts and drug recalls
Selection error error that occurs when 2 or more options exist and the incorrect option is chosen
Created by: Tara3184