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)

harm experienced by a patient that results from exposure to a medication

near misses

errors in medications that are caught before they can result in injury

Institute for safe Medication practices (ISMP)

non profit organization devoted entirely to error prevention. know as the gol standard for medication saftey

tall man lettering

mixed letter cases used to emphasize the difference in drug names that look alike or sound alike. used on the most different part of two drug names

use a leading zero

when writing decimal points add a zero before the decimal point

use “0.5g” instead of “.5g” to avoid patient error

avoid a trailing zero

when using whole numbers do not add a decimal point after the hole number

use “5g” instead of 5.0g” to avoid patient error

avoid error prone abbreviation

Institute for Safe Medication Practices (ISMP) and The Joint Commission (TJC) provide a list of error-prone abbreviations that are not to be used.

Most common do not use abbreviations:

• IU (international units) can be mistaken for IV (intravenous): write units instead

• QD (every day) can be mistaken for QID (four times a day): write daily instead

• MgSO4 (magnesium sulfate) can be mistaken for morphine sulfate: write out full drug names

• SS (roman numeral for .5) can be mistaken for 55: write out “one half” or “0.5”

the joint commission (TJC)

the accreditation group that develops patient safety and care standards for hospitals and other healthcare facilities

barcorde and QR code scanning

barcodes include the drugs unique NDC number

QR codes include the NDC as well as the product lot number and expiration date

anatomy on an NDC number

divided into 3 segments:

• first segment: identifies drug manufacture

• second segment: identifies drug

• third segment: identifies package size

e-prescribing & verbal read back

electronic prescriptions for easier interpretation, faster dispensing and more efficient record keeping

verbal read back: prescriptions gathered over the phone must be written down and read back to the prescriber to confirm accuracy.

7 rights of medication administration

right patient

right medication

right dose

right route

right time

right indication

right documentation

Risk evaluation and mitigation strategies (REMS)

A drug safety program that the FDA can require for certain medications

• Unique to each drug

• require prescriber and patient registration

• require consent to monitoring, such as blood testing

common REMS program drugs

Clozapine: REMS programs reduce the risk of severe neutropenia

iPLEDGE REMS program: helps to reduce the risk of severe birth defects with isotretinoin

Beers Criteria: The American Geriatrics society

The American Geriatrics society establishes and oversees the Beers criteria for inappropriate medication use in older adults.

These medications contribute to confusion, falls, and mortality

Examples of Beers Criteria Drugs

First-generation antihistamines (ex: diphenhydramine)

antiparkinsons agents (ex: bromocriptine)

antithrombotics (ex: clopidogrel)

anti-invectives (ex: nitrofurantoin)

Alpha-1 blockers (ex: terazosin)

Benzodiazepines (ex: alprazolam)

hypnotics (ex: zolpidem)

NSAIDs (ex: ibuproprofen)

Tricyclic antidepressants (ex: nortriptyline)

Skeletal muscle relaxants (ex: cyclobenzaprine)

tasks that are to be exclusively performed by a pharmacist

• DURs

• Therapeutic substitution

• patient counseling

• Final verification of prescriptions

Medwatch

a voluntary program established by the FDA to report adverse reactions observed in human medical products

FDA adverse event reporting systems (FAERS)

a database that contains information on adverse event and medication error reports submitted to the FDA

vaccine adverse event reporting system (VAERS)

co sponsored by the FDA and CDC. collects and analyzes data from adverse events after vaccination

MEDMARX

online anonymous error reporting program designed for hospitals and health systems.

ran by the united states pharmacopeia (USP)

how often should counting trays be cleaned

once daily with %70 isopropyl alcohol

food and drink pharmacy policy

medication storage areas including refrigerators cannot contain food or drinks

how often should countertops be cleaned

once daily with 70% isopropyl alcohol

contaminated crash carts must?

be disinfected

shelves, floors, and storage areas must?

be cleaned routinely and free of clutter