Intro to Medication Safety (TEST 3)

to promote safe use of medications to improve patient health

What is the goal of medication safety?

sentinel

system issue that may result in similar issues in the future

medical error

•Unintended act or

•omission or

•commission

•Does not achieve its intended outcome,

•Failure of a planned action to be completed as intended (error in execution),

•Use of a wrong plan to achieve an aim, or

•Deviation in process of care

•May or may not cause harm to a patient

•Violate “standard of care”

error of omission

provider did not take action when they should have

error of commission

healthcare provider taking some kind of affirmative action that changed that patient's outcome

adverse drug events

injury related to a drug

adverse drug reaction (ADR)

noxious of unintended response to a drug at normal doses

1/4

What fraction of medical errors are medication errors?

organizations involved in medication safety

•Food and Drug Administration (FDA)

•The Joint Commission (TJC)

•World Health Organization (WHO)

•Institute for Safe Medication Practices (ISMP)

•The United States Pharmacopoeia (USP)

•American Society of Health-System Pharmacists (ASHP)

•National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

•Institute for Healthcare Improvement (IHI)

seek care -> problem diagnosed -> tx regimen chosen -> prescription sent to pharmacy -> pharmacy fills prescription -> patient picks up rx

What is the medical care process?

-initiating therapy

-monitoring therapy

-managing therapy

What are the 3 key elements to the proper functioning of the pharmaceutical care system?

-right patient

-right drug

-right dose

-right time

-right route

What are the 5 rights?

conformation bias

"see what you want or expect to see" similarities in med packaging, look-alike/sound alike drug names

inattentional blindness

(pereptual blindness) occurs when an individual fails to perceive something purely as a result of a lack of attention ; the brain filters away important information and fills in the gaps

medication error- transcribing

-entering a med that the patient is allergic to

-taking a verbal order and not hearing correctly

•Leads to a Better characterization of errors:

•Identifies trends in errors

•Developing lessons learned and tactics for preventing similar errors in the future that are then shared locally and nationally

How does reporting med errors and near misses help prevent errors?

-warfarin

-corticosteroids

-hypoglycemic agents

-digoxin

-amoxicillin

-phenytoin

What are the drugs that are most often involved in pharmacist malpractice cases?

category A

circumstances or events that have the capacity to cause error

category B

an error occurred but the error did not reach the patient

category C

an error occurred that reached the patient but did not cause patient harm

category D

an error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm

category E

en error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention

Category F

an error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization

category G

an error occurred that may have contributed or resulted in permanent patient harm

category H

An error occurred that required intervention necessary to sustain life

harm

impairment of the physical, emotional, or psychological function or structure of the body and or pain resulting therefrom

monitoring

to observe or record relevant physiological or psychological signs

intervention

may include change in therapy or active medical/surgical treatment

intervention necessary to sustain life

includes CV and respiratory support

Help health care practitioners and institutions to track medication errors in a consistent, systematic manner

What is the goal of categorization of medication errors?

punitive, blame free, and just culture

What are the safety culture types?

punitive

Those who make an error are held personally responsible, regardless of the root cause

Blame free

Encourage reporting of errors as there was no risk of punishment, regardless of the cause of the error

Just Culture

-Focus is on the cause of the error, and therefore errors caused by system failures are not punished

-Reckless or negligent behaviors that lead to errors are punished