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Differentiate between medication errors and adverse drug events
Identify opportunities for errors in pharmacy practice and classification medication errors according to the types of drug-related problem
State appropriate actions that a pharmacist should take after a medication error
Analyze the characteristic of a successful reporting system to enhance safety practices and facilitate a culture of improvement
Develop methods to reduce the likelihood of error given a unique, challenging setting or patient population with various risk factors
What are medication errors?
preventable events that cause or leads to inappropriate med use or patient harm
What are adverse drug events (ADE)?
injury resulting from medical intervention related to a drug
What are adverse drug reactions (ADR)?
any response to a drug which is noxious and unintended occurring at normal doses
What are common risk factors for medication errors?
transition of care, multiple providers, poly-pharmacy (5+ meds), 65+ years, health literacy, delayed response, and look alike/sound alike
What are the medication error classifications?
1. error of commission
2. error of omission
What is an error of commission?
2 drugs of the same type for 1 disease state
What are subtypes of errors of commission?
correct vs incorrect drug
What does it mean when the medication error is of commission and is the correct drug?
dose too high, dose too low, ADR, or interaction
What does it mean when the medication error is of commission and it the incorrect drug?
wrong or unnecessary drug
What is error of ommission?
no drug is prescribed for an indication or the med is not starting after discharge
What do we do if no drug is prescribed for an indication?
this error is classified as needing additional therapy or inappropriate compliance/adherence
What are possible results of drug-related problems?
injury vs no injury
What happens if drug-related injury occurs?
can either be morbidity or latent injury
What is latent injury?
may cause harm in the future, but not right now
True or False: if a medication error occurs, the pharmacist should not be the one responsible for approaching the involved staff members
False
the pharmacist should directly approach staff members involve and investigate BUT DO NOT BLAME
What is the goal of reporting medication errors?
prevent harm to patients but not eliminate errors
What are characteristics of managing med errors?
define roles,
have written policy,
response asap with concern, compassion, empathy,
be honest,
maintain emotions,
gather medical info for pt,
document and report the event,
support staff involved,
establish quality improvement programs
How to build a safe system:
What is "Just Culture"?
atmosphere of trust and it encourages providing safety-related accountability with clear definitions
Within just culture, how do we approach an error?
How did the error occur?
How can it be prevented in the future?
Within just culture, how do we NOT approach an error?
with blame
How should we approach human error within just culture?
console
How should we approach at-risk behavior within just culture?
educate
How should we approach reckless behavior within just culture?
punish
What is quality improvement?
systematic implementation of changes measurably improve patient care
True or False: quality improvement can be measured, is never-ending, and has specific goals
True
it's easier to make improvements when it can be measured
What are the laws of QI?
re-frame performance from effort to system design;
transparency and learn from failure;
attitude (willing to fail, humility);
agility (fail or succeed quickly);
team-based
What can be measured within just care?
active and passive surveillance
What is active surveillance?
data from EHR or databases
What is passive surveillance?
clinician or patient voluntary reports to a system
What are examples of active surveillance?
1. AHRQ medicare patient safety monitoring system
2. CDC national electronic cost and utilization report
What is an example of passive surveillance?
FDA adverse event reporting
