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Chapter 8
Medication Errors, Patient Safety, and the joint commission
| Question | Answer |
|---|---|
| someone (prescriber, pharmacist, nurse, or patient)did something that was not correct (wrgong drug, strength, route, or dose of the medication etc... | medication error |
| who is responsible for errors the individual or the system? | problems with design of the medical system itself could catch misttakes before reaching the patient |
| this kind of analysis investigates an event that has already occurred (retrospective)... looks back at the sequence of events that led to the error | root cause analysis* |
| the information obtained in a ____________ analysis is used to design changes that will hopefully prevent future errors | root cause* |
| what are the steps in root cause analysis? | define goals (what's the problem), analyze causes (why did it happen), prevent solutions (what will be done) |
| the unexpected occurrence involving death or serious physical or psychological injury or risk therof | sentinel event* |
| what is the best way to prevent similar problems from occurring in the future? | targeting corrective measures at the identified root causes |
| RCA (root cause analysis is considered a ________ process and is frequently viewed as a __________ tool | repetitive; continuous quality improvement CQI tool |
| what type of analysis is done prospectively to identify pathways that could lead to errors and identify ways to reduce error risk? | Failure mode and Effects Analysis (FMEA)* |
| a proactive prospective analysis to reduce frequency and consequences of errors | FMEA* |
| this type of error means leaving something out that is needed for safety such as missed instructions or failure to provide a dose at the required time | errors of omission* |
| if hydrocholorthiazide is dispensed without lisinopril and the pt requires both... what kind of error is that? | error of omission* |
| this type of error means something was done incorrectly (prescribing buproprion to a pt with history of epilepsy or dispensing sulfamethoxazole to a pt with sulfa allergy) | error of commission* |
| if an error occurs in a hospital, the ________ should be informed of the error as well as the _________ | P&T committee and Medication safety committee* |
| The P&T committee is required to recored errors and responses to the _______________ | Joint commission* |
| in a community pharmacy the staff memmber who discovers the error should immediately report it to the ____________ or if its independent pharmacy to the ______ | corporate office; owner |
| the patient safety act authorized creation of ___________ to improve the quality and safety of health care deliver in the US | Patient safety organizations |
| the ______________ is a confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and disseminites recommendations for prevention | ISMP national Medication Error Reproting Program (MERP) |
| this program was created by the omnibus Budget Reconciliation act of 1990 OBRA , the main emphasis is to promote patient safety by an increased review and awareness of outpatient prescribed drugs | Drug Utilization Reviews (DURs) |
| this program mandated under Medicare part D to promote safe and effective medication use | MTM |
| process of avoiding inadvertent inconsistencies and or medication errors such as omissions, duplications, dosing errors or drug interactiosn ACROSS TRANSITIONS OF CARE* | Medication reconciliation* |
| medication reconciliation is accomplished by reviewing the patients complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the ____________ | new setting of care* |
| these present IMPORTANT ADVERSE EVENTS* that can occur with over 300 medications (should be dispensed with the original rx and with each refill) | Medication guides* (medGuides) |
| these are FDA approved patient handouts that are considered part of the drug labeling (should be dispensed with the original rx and with each refill) | Medication Guides* (MedGuides) |
| voluntarily provided with new prescriptions by retail pharmacies | CMI (consumer medication information) leaflets |
| What may be the MOST IMPORTANT MEDICATION ERROR REDUCTION TOOL | Bar Coding* |
| The use of _____________ can help distinguish similar drug names, making them less prone to mix-ups | Tall man letters |
| ______________ are unsafe and ocntribute to many medical errors | abbreviations* |
| an ____________________ that is written on the rx helps us assure the _______________ | indication for use; appropriate prescribing and drug selection |
| measurements should be kept in the ____________ | metric system* (weights, volumes, units) |
| the term _________________ is NOT acceptable on rx | Use as directed* |
| drugs that bear a heightened risk of causing significant patient harm when used in error should be designated as _________________ | high alert* |
| crash cart medicatiosn should be ____________ and _______________ | unit dose; age specific* |
| staff education programs such as ____________ should be provided whenever new drugs are being used in the facility, if there aer procedure changes and to discuss medical errors and prevention and if ther are new therapeutic guidelines | in services* |
| many hospitals now limit the use of ________________to provide drug education due to inherent bias | pharmaceutical companies* |
| ______________ for high risk drugs increase the rate of appropriate prescribing based on published recommended guidelines and reduce the chance of errors due to inappropriate prescribing | standard protocols* |
| the joint commission requires that _________________ should exist for all antithrombotics | standard order flow sheets* |
| this allows direct entry of medical orders by prescribers | computerized prescriber order entry* |
| if the patient asks a question about the medication dispensig process or drug appearance, dose or something else, the pharmacist must be receptive and responsive and NOT ___________________ | defensive* |
| an FDA program that requires specified training and various restrictions on certain drugs | REMS (risk evaluation and mitigation strategies) |
| the following are examples of what? (clozapine patient registry, APRISE program for EPO use in oncology, the iPLEDGE program for isotretinoin and others | REMS |
| _________ drug delivery can mimic the pain more closely and provide good pain control | PCA's (patient controlled analgesic)* |
| the joint commission requirement is that _______ and _______ should not administer PCA doses | friends and family members |
| with PCAs it is important to | *limit opiods available in floor stock, educate staff about hydromorphone and morphine mix ups, implement PCA protocols that include double checking of the drug, pump setting, dosage, MAR should match PCA label, use bar coding assess patients pain,sed,rr |
| the joint commission requires that hte pharmacist to _____ the order before it can be removed from the ADC except in ______________ | review; special circumstancies |
| certain meds that cannot be put in the ADC's (automated dispensing cabinet) | high dose narcotics (hydromorphone 10mg/ml, morphine 20mg/ml) and warfarin |
| common types of nosocomial acquired infections: | UTI from indwelling catheters, blood stream infxns from IV lines (central)&catheters, srugical site infections, c.difficile, pneumonia (ventilator use)**** others not underlined: decubitus ulcers, hepatitis |
| to prevent a nosocomial UTI you should | remove the indwelling catheter as soon as possible |
| what lines have the highest risk of blood stream infections | central IV lines |
| _____________ are more effective in the healthcare setting for preventing the spread of infection | alcohol based hand rubs |
| when to wash hands: | before entering and leaving patient rooms, between pt contacts if more than one pt in room, before and after removing gloves, before handling invasive devices, after coughing/sneezing, before handling food and oral meds |
| use soap and water (NOT alcohol based rubs) in what situations? | before eating, after using rr, anytime there is visible soil, after caring for pt with diarrhea or known c.diff or spore forming org.**, before caring for pts with food allergies |
| alcohol based hand rubs have poor activity against ____________ | spore forming organisms (ex: c.diff)* |
| soap and water technique | wet both sides of hands, apply soap, rub together for 15 secs, rinse throughly, dry with paper towel and use towel to turn off water |
| alcohol based hand rubs technique | use enouh gel, rub hands together until rub dries (15-25 secs), hands should be completely dry before putting on gloves |
| patients can be placed in isolation if they are at high risk for getting an infection such as __________ or have a highly contagious infection such as _______________ | bone marrow transplant pts; VRE or tuberculosis |
| NEVER__________ used needles into a multiple dose vial or solution container | Reinsert* |
| use of ________ vials is preferred over multiple dose vials | single dose* |
| never touch the ________ or ________ of a syringe | tip or plunger* |
| disposable needles contaminated with drugs, chemicals, blood products should never be removed from their ____________ | original syringes |
| throw the entire ___________ assembly into the red plastic sharps container | needle/syringe* |
| used disposable needles/sharps should be discarded immediately after use without _________ into a sharps container | re-capping* |
| never ________ the contents of any sharps container | compress or push down* |
| __________ means that the air is moving in an uninterrupted constrant stream | Laminar flow* |
| air through a laminar flow is drawn through ____________ that catches particulates | HEPA Filter* |
| HEPA filters remove 99.97% of all air particles ________ or larger | 0.3 mm |
| ____________ flow hoods blow air from the top down and are also called ____ or ___ | vertical flow hoods; biological safety cabinets or chemotherapy hoods |
| chemotherapy is made using _____ hood as to protect the person preparing the med from breathing in the dangerous fumes | vertical flow hood |
| THe __________ accredidates institutions | joint commission |
| the joint commission sets up ___________ that are set annually | National patient safety goals (NPSG's) |
| National patient safety goals include: | reduce likelihood of harm with anticoagulant therapy, maintain and communicate accurate patient medication information, comply with CDC hand hygeine guidelines, implement evidence based practices to reduce healthcare ass. infections,use at least two pt id |
Created by:
rxprepchapters