Prevention and Management of Medication Errors (TEST 3)

iceberg theory

What theory is good to use when thinking about errors?

move beyond blame to system correction

What is the goal of systems based thinking?

slips and lapes: "skills-based errors"

-Unintended and "not planned"

-Often occur during familiar tasks

-Attention/concentration diverted from task at hand

-"skill based errors"

mistakes

-Intentional, but usually well-meaning

-Error in problem solving or judgement

-Clinical decisions based on assumptions or on previous experience: “Rule-based errors”

-Lack of knowledge or information (poor training): “Knowledge-based errors”

-Non-compliances, circumventions, shortcuts, and work-arounds

-Can be caused by peer pressure, unworkable rules, and incomplete understanding

self-awareness

ability to understand one's thoughts, feelings, and behavior

self-concept

beliefs, attitudes, values

self-esteem

confidence and self worth

self-disclosure

sharing or personal information and emotions with oneself

inattention blindness

Multi-tasking is a major contributor to __________________.

joint commission data

continues to demonstrate the importance of communication in patient safety​

effective communication

encourages effective teamwork and promotes continuity and clarity within the patient care team

-collaboration

-teamwork

-opportunity to prevent error

What are good communication fosters?

create a positive care environment

What does effective communication create?

failure mode and effects analysis (FMEA)

•Think about everything that COULD go wrong to then develop safeguards

•Pre-implementation of a new process or piece of equipment or technology

root cause analysis (RCA)

•Get beyond the direct cause (action that happened just prior to the event)

•Ask why until you cannot ask why any longer...

apparent cause analysis (ACA)

•Focus on events that result in no harm, minimal harm, and near miss events

•Identify actions to address the problem/immediate condition

•Collect event information that aids in the development of organizational trends

•Gives structure to learning and understanding about the event and facilitates creating an action plan that prevents recurrence

Common cause analysis (CCA)

•Review of multiple events looking for commonalities

•Aggregation of events and identification of themes common to events

standard operating procedures

A protocol which details how a certain procedure should be carried out every time it is performed

pharmacists ;)

Who is most commonly responsible for wrong drug dispensing errors?

trigger tools

•Targeted Injury Detection Systems "Clues"

•Retrospective review to identify errors and adverse events

•Measure the frequency they occur

•Track progress of safety initiatives

outpatient tactic: drug utilization review (DUR)

Authorized, structured, ongoing review of prescribing, dispensing and use of medication

1) prospective

2) concurrent

3) retrospective

What are the 3 categories that drug utilization review are classified under?

prospective

evaluation of a patient's drug therapy before medication is dispensed

concurrent

ongoing monitoring of drug therapy during the course of treatment

retrospective

review of drug therapy after the patient has received the medication

DUR Rejections

Requires review before filling a prescription usually due to (high dose, drug interaction, excessive utilization, etc.)

prospective

Third part payers do ___________ DUR- mandated by OBRA 90 federal law for Medicaid.

S-stop

T-think

A-act

R-review

What does STAR stand for?

communication tactics

•Repeat back

•Use clear language (phonetic and numeric clarification)

•Asking clarifying questions

S-situation

B-background

A-assessment

R-recommendation

What does SBAR stand for that is used for escalation?

I-Illness severity

P-patient summary

A-action list

S-situation awareness and contingency planning

S-synthesis by reciever

What does I-PASS stand for?

tools and tactics

What can you use to minimize human errors?