PTCB - Patient Safety and Quality Assurance

Medication error

any preventable event that may lead to inappropriate medication use or patient harm

Adverse drug event (ADE)

exposure to a medication that results in harm to a patient

The Institute for Safe Medication Practices (ISMP)

a non-profit organization aimed at error prevention and is known as the gold standard for medication safety

Tall-man lettering

emphasizing differences in letters of look alike or sound alike medications (only the differing letters are upper-case)

BuPROpion/BusPIRone

Should leading zeros be used?

Yes

Should trailing zeros be used?

No

The Joint Commission (TJC)

the accreditation group that develops patient safety and care standards for hospitals and healthcare facilities; it also developed the “Do Not Use” list for certain confused abbreviations

National Drug Code (NDC)

a unique three-segment number that identifies a drug product

NDC first segment

identifies the drug manufacturer

NDC second segment

identifies the drug

NDC third segment

identifies the package size

E-prescribing

an electronic method that can help reduce errors that might occur from misinterpreting handwritten prescriptions

E-prescribing speeds up the process of _______ ________ and saves paper, time, and storage space

insurance verification

Medication errors occur when ______ ______ lead to the incorrect use of medications

human factors

Distractions

lapses in judgment when interrupted or multi-tasking

Omissions

an ordered dose of a medication is not administered

What are the “7 rights” of medication administration?

1. Right patient

2. Right medication

3. Right dose

4. Right route

5. Right time

6. Right indication

7. Right documentation

Risk Evaluation and Mitigation Strategies (REMS)

a drug safety program that places strict criteria and procedures for the prescribing and dispensing of medications with serious safety concerns, which is required by the FDA for the medications’ manufacturers

What are the most commonly prescribed drugs with REMS programs?

1. Clozapine REMS: helps ro reduce the risk of severe neutropenia associated with the psychiatric drug

2. iPLEDGE REMS: helps to reduce the risk of severe birth defects with isotretinoin, an anti-acne drug

American Geriatrics Society (AGS)

establishes and oversees the Beers Criteria/Beers List for Potentially Inappropriate Medication Use on Older Adults

What are Beers medications?

medications that have been associated with poor outcomes for older patients, such as confusion, falls, and mortality

What should pharmacists do when they receive warnings for Beers Criteria medications?

they must contact the prescribers to discuss if the therapy is appropriate or if alternative therapies would be safer

Are pharmacy technicians allowed to perform drug utilization review (DUR)?

No, that is a duty of the pharmacist

Therapeutic substitution

the replacement of the originally-prescribed drug with an alternative with assumed equivalent therapeutic effect (may be from the same class or have therapeutic equivalence)

MedWatch

A voluntary program established by the FDA to report adverse or sentinel events that are observed in human medical products

Sentinel event

an event that results in death, permanent harm, or severe temporary harm to the patient

FDA Adverse Event Reporting Systems (FAERS)

A database that contains information on adverse event and medication error reports submitted to the FDA; the reports are submitted by healthcare professionals and consumers

Vaccine Adverse Event Reporting System (VAERS)

A program that collects and analyzes data from adverse events after vaccination, with the goal of identifying new safety concerns that were not discovered during clinical trials

VAERS is co-sponsored by the ___ and ___

FDA; CDC

MEDMARX

An anonymous online error-reporting program designed for hospitals and health systems, and it is overseen by the United States Pharmacopeia (USP)

Counting trays should be cleaned ____ daily with ___________

once; 70% isopropyl alcohol

Countertops should be cleaned _____ with ___________

daily; 70% isopropyl alcohol