understanding med errors - ogden

__________ is the failure of a therapeutic agent to produce the intended therapeutic outcome

drug-related morbidity

___________ is an event or circumstance involving drug treatment that actually or potentially interferes with the patient experiencing an optimum outcome of medical care

drug-related problem

T/F drug-related problem is typically preceded by a drug-related morbidity

FALSE — other way around

what category of drug-related problem is this:

patient is in need of a drug that was not prescribed

a. untreated indications

b. improper drug selection

c. subtherapeutic dosage

d. overdosage

a.

what category of drug-related problem is this:

wrong drug is being used

a. untreated indications

b. improper drug selection

c. subtherapeutic dosage

d. overdosage

b.

what category of drug-related problem is this:

too little of an appropriate drug is being used

a. untreated indications

b. improper drug selection

c. subtherapeutic dosage

d. overdosage

c.

what category of drug-related problem is this:

patient receives too much of an appropriate drug

a. untreated indications

b. improper drug selection

c. subtherapeutic dosage

d. overdosage

d.

what category of drug-related problem is this:

patient does not obtain/use the drug that was prescribed

a. failure to receive drug

b. adverse drug reaction

c. drug interactions

d. drug use without indication

a.

what category of drug-related problem is this:

unintended and potentially harmful effect of a drug

a. failure to receive drug

b. adverse drug reaction

c. drug interactions

d. drug use without indication

b.

what category of drug-related problem is this:

undesirable consequences of drug-drug or drug-food interactions

a. failure to receive drug

b. adverse drug reaction

c. drug interactions

d. drug use without indication

c.

what category of drug-related problem is this:

patient is taking a drug for which he or she has no medical need

a. failure to receive drug

b. adverse drug reaction

c. drug interactions

d. drug use without indication

d.

what are the three key elements to proper functioning of the pharmaceutical care system?

initiating therapy

monitoring therapy

managing therapy

list patient issues that cause problems with therapy initiation

lack of recognition or reporting

misinterpretation

lack of knowledge

fear

lack of trust

inability to pay

geographic barriers

inability to communicate

lack of adherence

list prescriber issues that cause problems with therapy initiation

lack of understanding pt

lack of knowledge, skills, equipment, info

inadequate attention

list pharmacist issues that cause problems with therapy initiation

lack of knowledge

lack of focus

ambiguous DUR alerts

large volume of “low-risk alerts”

lack of pt health info

what are some sources for error with drug names?

look-alike, sound-alike

trademark suffixes

Ad Hoc abbreviations

brand name extensions

foreign drug names and re-importation

_____ and _____ have paired together to advocate for a number of proprietary name changes

ISMP and FDA

________ committee works to develop generic names worldwide

WHO International Nonproprietary Names (INN)

USAN council assigns it in the US after approval from WHO INN

_________ publishes national patient safety goals annually and takes action

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

_______ reviews all trademark proposals for error prone potential

FDA Office of Drug Safety, Division of Medication Errors and Technical Support (DMETS)

___________ annually reviews a list of common name mix-ups and recommends preventative strategies

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals (NPSG)

you should NEVER use _________, and ALWAYS use __________

a. trailing zeros, leading zeros

b. leading zeros, trailing zeros

a.

failure of healthcare providers to initiate or intensify therapy when indicated due to:

overestimation of care provided

use of “soft” reasons to avoid intensification of therapy

what’s something pharmacists can take advantage of when it comes to problems with monitoring and managing drug therapy?

seeing pts monthly for refills

T/F fixing information flow itself will not solve all errors

TRUE

______ and ______ may also impede pharmacists from utilizing new information even if it is provided

work pace and environment

what phrase is associated with the Hippocratic Oath?

first, do no harm

a clinician error is a violation to ______

a. patient

b. clinician

c. both

c.

who is considered “the second victim” in a patient safety event?

the healthcare provider involved

bc it traumatizes them

the pharmaceutical care system involves (SATA)

a. initiating therapy

b. monitoring therapy

c. improving therapy

d. managing therapy

a. b. d.