informatics quiz

what is a med error

any preventable event that causes wrong med use or pt harm

what is to err is to human initiatve (1999)

publication about teh problem, emphasis need for voluntary reporting, numbers exposed

what was preventing med errors initiative (2006)

• 1.5 million preventable ad eff in US

• rec safety strats for all stages of med use process

what act established patient safety organizations?

patient safety and quality improvement act of 2005?

what is an ad drug event (AE)

any injury or harm to a patient resulting from the use of a medication. AEs include harm caused by errors and ADRs

ad drug rxn (ADR)

noxious (poisonous) and unintended response to a medication taht cocurs at doses normally used in humans for proph, diagnosis, or thearpy

what is a near miss

error occrued but detected and corrected before reaches pt

sentinel event

unexpected occurance invovling death/serious

first steps in medication use system until patient admission

planning

selection and procurement

storage

patient admission

steps in med use sytem from pt admisison to administration

pt admission

order, transcribing, reviewing

preparing

dispensing

administration

what are steps in med use system from administration to evualation

administration

monitoring

pt discharge

evaluation

what kind of condition can be predicted

latent

which failure is a result of system

latent

which is result of unsafe acts by providers

active failures

what are teh five things need to get right

dose, drug, patient, route, time

what are the four error detection methods

• voluntary reporting

• chart reviews

• direct observation

• information technology

which error detection method takes a lot of time and labor; doesn’t detect a lot of serious issues esp in association with hawthorne effect

direct observation

which error detection method is useful for identifying adverse drug reactions

chart review

what does category a mean

error prone conditions

what does B category mean

error did not reach patient (near miss)

what does c category mean

error reached pt with no harm

what does d category mean

error required monitoring or intervention to confirm no harm

what does E category mean

error contributed to temporary harm

what does F category mean

error contributed to temporary harm and some hospitalization

what does G category mean

error contributed to permanent harm

what does H category mean

error required life-saving intervention

what does I category mean

error contributed to pts death

what is the joint commission? what do they publish that is relevant to med error?

non-profit organization that accredits and certifies over 22,000 healthcare organizations and programs in the United States

• do not use list

what is ismp

Institute for Safe Medication Practice

why are insulins high risk

strengths— U-100 , U-200

why are Antithrombotic agents confused

Direct oral anticoagulants and factor Xa inhibitors (e.g., dabigatran, rivaroxaban, apixaban, edoxaban)

chemotherapeutic agents why are they confused/what are the names

Oral targeted therapy and immunotherapy (e.g., palbociclib [IBRANCE], imatinib [GLEEVEC], bosutinib [BOSULIF])

what are the immunosuppressant agents that gets confused

(e.g., azaTHIOprine, cycloSPORINE, tacrolimus)— oral vs parenteral

why are opioids confused

phines/phones/codones— morphine, hydromorphone, hydrocodone, oxycodone

etc

what are commonly hospital meds

• adrenergic agonists, antagonists (epinephrines; -lols)

• antithrom— anticoag; factor Xa inhib; glycoprotein 2b/3a inhib; thrombolytics (alteplase, reteplase, etc)

• insulins

• neuromuscular blocking agents (succinylcholine, rocuroinium)

• opioids, including dif routes of administration

li

list 10 elements of med use system

1. pt info

2. drug info

3. miscommunication

4. drug name, labelling, packaging

5. drug storage, distrubution

6. drug delivery device