recognizing and defining quality problems - ogden

which of the following is this:

an injury resulting from a drug-related intervention

a. adverse drug event (ADE)

b. medication error

c. adverse drug reaction (ADR)

d. drug misadventure

a.

which of the following is this:

a deviation from the prescriber’s order

a. adverse drug event (ADE)

b. medication error

c. adverse drug reaction (ADR)

d. drug misadventure

b.

which of the following is this:

an injury resulting from taking a medication appropriately

a. adverse drug event (ADE)

b. medication error

c. adverse drug reaction (ADR)

d. drug misadventure

c.

what is a broad term including both ADRs and medication errors?

drug misadventure

T/F error reporting should be a routine part of practice

TRUE

list types of error

1. unauthorized dose

2. extra-dose

3. omission

4. wrong dose

5. wrong route

6. wrong time

7. wrong dosage form

8. wrong technique

what are ways that people do not address problems?

avoidance

denial

unimportant

denying responsibility

procrastinating

linear thinking is a simplistic approach that assumes _________

each problem has a single cause

the solution will only affect the problem and nothing else

solution will remain “solved” once implemented

__________ often results in ineffective solutions and even more problems

linear thinking

list problems with linear thinking

problems usually have multiple causes

focuses on intended consequences of solution

makes false assumption that no further action or follow up is needed after implementing solution

_______ is preferred for dealing with complex quality issues in healthcare

systems thinking

systems thinking assumes ________

causes of problems are complex

solutions have both intended and unintended consequences

in systems thinking, solution is evaluated for how well it _____

solves the problem and minimizes negative unintended results

a systems thinker considers the ________ before implementing a solution

interrelationships among different systems

what are the two main effects of faulty system design?

cause of operator error

creates difficulty with timely error detection

what is the swiss cheese model?

multiple layers of defense may prevent an event from occurring, but occasionally the holes may line up just right for an event to occur

list obstacles for re-design

1. a culture of shame and blame

2. infrequent occurrence of serious events

3. complexity and lack of ownership

4. unavailability of information

5. physician resistance

6. lack of leadership

7. tolerance of individualistic practices

what are the two key steps in solving a quality problem (regardless of process)?

recognize the existence of a problem

clearly define the problem

what is the first step in solving any problem?

recognizing the existence of a problem

why may problems be difficult to recognize?

stem from gradual change

what’s a solution to problems going unnoticed?

statistical processes

list methods for error detecting

anonymous self-reporting

incident reports

critical incident technique

chart review

computerized monitoring

observation

list the 2 modes of mental functioning

1. automatic mode

2. problem-solving mode

errors in this mode are called slips

a. automatic mode

b. problem-solving mode

a.

errors in this mode are called mistakes

a. automatic mode

b. problem-solving mode

b.

what is “framing the problem”?

how a question is set up to be answered

considers:

-perspectives taken

-elements of the problem to consider

-criteria used to choose the solution

_______ can lead to poor decisions when choosing a solution to a problem

framing biases

list types of framing bias

1. defining problems with solutions

2. anchoring

3. confusing symptoms with problems

4. seeing the world from a pharmacist’s viewpoint

5. knowing the “truth”

how can you fix framing bias: seeing the world from a pharmacist’s viewpoint?

make a conscious effort to think from others’ perspectives

what is a single short sentence that defines the broad problem to provide focus and avoid distractions to the issue?

problem statement