Patient Safety and Quality Assurance

Medication Error

any preventable event that may lead to inappropriate med use/patient harm.

Adverse Drug Event (ADE)

harm experienced by a patient that results from exposure to a med.

Near misses

errors caught before injury

Tall-man lettering

use of mixed-letter cased to emphasize difference in drug names that look alike/sound like.

BuPROpion/BusPIRone, HydrALAZINE/HydrOXYzine, PredniSONE/PrednisoLONE

Medication Reconciliation

comparing patient’s inpatient med orders w/ all of outpatient meds. Avoids med duplication, omission, drug interactions.

Institute for Safe Medication Practices (ISMP)

non-profit organization devoted to error prevention and is known as the gold standard for med safety: Tall man lettering, use leading zero, avoid trailing zero, avoid error prone abbreviations, verbal order read back, barcode/QR code scanning, e-scribing, 7 rights of med admin, rems, beers criteria. 

The Joint Commission (TJC)

certain abbreviations do not use list, develops patient safety standards for hospitals/healthcare facilities. 

Error prone abbreviations

IU (international units) mistaken for IV, write units instead.

QD mistaken for QUID, write every day or daily instead. 

Write out full drug names.

SS mistaken for 55, write out one half or use 0.5.

Verbal order read back

CPHT can receive verbal prescriptions for non-controlled drugs vs phone and reduce to writing and read back to the prescriber to ensure accuracy but only in certain states. 

Barcode/QR Scanning

Used in community/hospital pharmacies to reduce dispensing errors. 

Barcodes include product’s NDC (national drug code) #. 

XXXXX(drug manufacturer)-XXXX(drug)-XX(package size)

QR codes: NDC, product lot #, expiration date

E-prescribing

reduce errors due to handwriting, lost prescriptions, speeds process of insurance verification, saves paper, time, storage space.

7 rights of med administration 

1: Right patient, 2: right med, 3: right dose, 4: right route, 5: right time, 6: right indication, 7: right documentation

Risk Evaluation and Mitigation Strategies (REMS)

Program FDA requires for manufacturers of certain meds that have safety concerns but usually require prescriber/patient registration/consent to monitoring such as blood testing.

Clozapine REMS program helps reduce risk of severe neutropenia. 

iPLEDGE REMS program reduces risk of severe birth defects with isotretinoin. 

Beers Criteria for Potentially Inappropriate med use in older adults

American Geriatrics Society (AGS)establishes Beers Criteria/Beers List.

Beers meds associated w/ falls, confusion, mortality.

Pharmacists should contact prescribers to discuss therapy is appropriate or alternatives if Beers criteria warnings.

First-generation antihistamines(diphenhydramine), anti-Parkinson agents(bromocriptine), anti-thrombotics(Plavix), anti-infective(Macrobid), alpha-1 blockers(Hytrin), benzodiazepines(Xanax), hypnotics(Ambien), NSAIDs(Advil), Tricyclic antidepressants(Pamelor), skeletal muscle relaxants(Flexeril) 

Pharmacy tech tasks

Create/maintain/update patient profiles, receive written/faxed/electronic prescriptions, perform prescription input, fill orders, alert pharmacist that require professional judgment, manage/restock/remove expired products from inventory, dispose of expired products per policy, maintain order/cleanliness, follow procedures to ensure security of prescription area, operate cash register. 

Tasks only for pharmacists

DUR, therapeutic substitution, patient counseling, final verification of prescriptions

MedWatch

voluntary program by FDA to report adverse events observed by medical products. (Submissions)

FDA Adverse Event Reporting Systems (FAERS)

Database for adverse event/ed error reports submitted to FDA. Reports from healthcare professionals/consumers. (Analysis of medwatch info)

Vaccine Adverse Event Reporting System (VAERS)

co-sponsored by FDA/CDC, collects data from adverse events after vaccination. 

MEDMARX

Anonymous online error-reporting program for hospitals/health systems. The United States Pharmacopeia (USP) oversees this program. 

Cleaning

counting trays/counter tops should be cleaned 1xd w/ 70% isopropyl alcohol. Med storage areas (fridge) cannot contain food/drinks. Contaminated crash carts must be disinfected. Shelves, floors, storage areas must be cleaned routinely/free of clutter.