Medication Safety

Front 1

Drug induced disease

Back 1

harm caused by an administration of a drug
~Example- a steroid causes an infection~

Front 2

Taxonomy

Back 2

The practice and science of classification. We use different taxonomies to classify adverse events

Front 3

Adverse Drug Event

Back 3

Harm to a patient due to a drug

Front 4

medication Error

Back 4

Any error in the medication use process

Front 5

Preventable Adverse drug Event

Back 5

Harm to a patient due to a drug that contains an error in the medication use process

Front 6

Ameliorable ADE

Back 6

A non-preventable ADE whose severity or length could be lessened

Front 7

Potential Adverse drug events

Back 7

Have potential to harm patients, but due to chance no harm actually occurs. Ex. pt with documented anaphylaxis to PCN is given Amox with no reaction.

Front 8

ADE'S vs. ADR's`

Back 8

Non-preventable ADE's are the same as ADR's

Front 9

Toxicity vs Efficacy

Back 9

Both are considered errors
Toxicity- Blood GLucose of 80 gets a dose of insulin
Lack of efficacy- Pt receives metformin with a glucose of 350 mg/dL

Front 10

Levels of severity

Back 10

Fatal
Life Threatening
Serious
Significant

Front 11

Why is Massachusetts a leader in ADE's

Back 11

we report them more. Other states are not good at reporting the ADE's

Front 12

5 Rights

Back 12

Right Patient
Right Med
Right Dose
Right Route
Right Time

Front 13

Levels of Preventability

Back 13

Probably preventable
Definately prevent.
Probably not prevent
Definate;y not prevent.

Front 14

NCCMERP

Back 14

Nat'l Coordinating Council for Med Errors Reporting and Prevention
`23 member organizations

Front 15

Latent Error

Back 15

Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas the active failure in a particular adverse event may have been a mistake in programming an intravenous pump, a latent error might be that the institution uses multiple different types of infusion pumps, making programming errors more likely. Thus, latent errors are quite literally "accidents waiting to happen."

Front 16

Drug induced disease

Back 16

harm caused by an administration of a drug
~Example- a steroid causes an infection~

Front 17

Taxonomy

Back 17

The practice and science of classification. We use different taxonomies to classify adverse events

Front 18

Adverse Drug Event

Back 18

Harm to a patient due to a drug

Front 19

medication Error

Back 19

Any error in the medication use process

Front 20

Preventable Adverse drug Event

Back 20

Harm to a patient due to a drug that contains an error in the medication use process

Front 21

Ameliorable ADE

Back 21

A non-preventable ADE whose severity or length could be lessened

Front 22

Potential Adverse drug events

Back 22

Have potential to harm patients, but due to chance no harm actually occurs. Ex. pt with documented anaphylaxis to PCN is given Amox with no reaction.

Front 23

ADE'S vs. ADR's`

Back 23

Non-preventable ADE's are the same as ADR's

Front 24

Toxicity vs Efficacy

Back 24

Both are considered errors
Toxicity- Blood GLucose of 80 gets a dose of insulin
Lack of efficacy- Pt receives metformin with a glucose of 350 mg/dL

Front 25

Levels of severity

Back 25

Fatal
Life Threatening
Serious
Significant

Front 26

Why is Massachusetts a leader in ADE's

Back 26

we report them more. Other states are not good at reporting the ADE's

Front 27

5 Rights

Back 27

Right Patient
Right Med
Right Dose
Right Route
Right Time

Front 28

Levels of Preventability

Back 28

Probably preventable
Definately prevent.
Probably not prevent
Definate;y not prevent.

Front 29

NCCMERP

Back 29

Nat'l Coordinating Council for Med Errors Reporting and Prevention
`23 member organizations

Front 30

Latent Error

Back 30

Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas the active failure in a particular adverse event may have been a mistake in programming an intravenous pump, a latent error might be that the institution uses multiple different types of infusion pumps, making programming errors more likely. Thus, latent errors are quite literally "accidents waiting to happen."

Front 31

Ex of latent errors

Back 31

Prozac/Provera
Clindamycin/Gentamycin

Front 32

Empathy

Back 32

One's ability to recognize, perceine and directly feel the emotion of another.
-put yourself in their shoes
"I feel your sadness"

Front 33

Sympathy

Back 33

"I am sorry for your sadness"

Front 34

Ways to act with empathy

Back 34

Ask "how do you feel?"
Assurance
Don't blame
the patient condition is paramount

Front 35

What is the purpose of National Patient Safety Goals?

Back 35

Evidence and expert based solutions to promote specific improvements in patient safety. An enforcable organization which recieves CMS functioning

Front 36

Goal 1A: patient identification with 2 identifiers

Back 36

Goal to reliably identify the person for whom the treatment is intended and to match a treatment to the individual
( ROOM NUMBER DOES NOT COUNT)
(specimen containers must be labeled in prescence of patient)

Front 37

Goal 1B: Patient identification before an invasive procedure

Back 37

"Time Out" A final verification process to confirm the correct pt., procedure and site using active and not passive techniques.

Front 38

Sentinel Event

Back 38

Any unanticipated event in a healthcare setting resulting in death or serious physical injury to a person or persons, not related to the natural course of the patient's ilness.

Front 39

#1 Cause of a Sentinel Event

Back 39

Ineffective Communication

Front 40

Goal 2A- "read-back" as a means to improving the effectiveness of communication among caregivers

Back 40

For verbal or TO's, verify the complete order by having the person receiving the info record and read back the complete order or test result.
-limit the # of ohone and verbal orders-
-Write down the complete order then read it back, then receive confirmation.

Front 41

Goal 2B- Official do not Use List as a means to improving the effectiveness of communication among caregivers

Back 41

Do not use:
1) U- instead write units
(mistaken for 4, zero, or cc)
2) IU- instead write international unit
(mistaken for IV or #10)
3)QD or QOD- write out every day or every other day
(mistaken for eachother or QID)
4)Trailing zero (X.0 mg) or lack of leading zero (.X mg) Instead write Xmg or 0.Xmg
(decimal point is missed)
5) MS and MS04 and MgSo4 instead write out morphine sulfate and magnesium sulfate
(mistaken for eachother)

Front 42

Goal 2C:
Critical results as a means to improving the effectiveness of communication among caregivers

Back 42

Must set up a system which defines what lab tests and results are critical and define an acceptable time for reporting

Front 43

Goal 2E: "hand off" communications as a means to improving the effectiveness of communication among caregivers

Back 43

S.B.A.R
Situation
Background
Assessment
Recommendation
plus time for Q&A

Front 44

Goal 3C: LASA meds as a way to improve the safety of using medications

Back 44

Identify and anually review a list of SALA drugs and take action to prevent interchange

Front 45

Examples of SALA drugs

Back 45

DOPAmine vs Dobutamine
Diazepam vs Ditropan
hydroxizine vs Hydralazine
Humulin vs Humalog
Novolin vs Novolog
Celexa vs Celebrex
Avandia vs Coumadin
Sertraline vs Seroquel
Topamax vs Toprol
Zyprexa vs Zyrtec

Front 46

Ex of latent errors

Back 46

Prozac/Provera
Clindamycin/Gentamycin

Front 47

Empathy

Back 47

One's ability to recognize, perceine and directly feel the emotion of another.
-put yourself in their shoes
"I feel your sadness"

Front 48

Sympathy

Back 48

"I am sorry for your sadness"

Front 49

Ways to act with empathy

Back 49

Ask "how do you feel?"
Assurance
Don't blame
the patient condition is paramount

Front 50

What is the purpose of National Patient Safety Goals?

Back 50

Evidence and expert based solutions to promote specific improvements in patient safety. An enforcable organization which recieves CMS functioning

Front 51

Goal 1A: patient identification with 2 identifiers

Back 51

Goal to reliably identify the person for whom the treatment is intended and to match a treatment to the individual
( ROOM NUMBER DOES NOT COUNT)
(specimen containers must be labeled in prescence of patient)

Front 52

Goal 1B: Patient identification before an invasive procedure

Back 52

"Time Out" A final verification process to confirm the correct pt., procedure and site using active and not passive techniques.

Front 53

Sentinel Event

Back 53

Any unanticipated event in a healthcare setting resulting in death or serious physical injury to a person or persons, not related to the natural course of the patient's ilness.

Front 54

#1 Cause of a Sentinel Event

Back 54

Ineffective Communication

Front 55

Goal 2A- "read-back" as a means to improving the effectiveness of communication among caregivers

Back 55

For verbal or TO's, verify the complete order by having the person receiving the info record and read back the complete order or test result.
-limit the # of ohone and verbal orders-
-Write down the complete order then read it back, then receive confirmation.

Front 56

Goal 2B- Official do not Use List as a means to improving the effectiveness of communication among caregivers

Back 56

Do not use:
1) U- instead write units
(mistaken for 4, zero, or cc)
2) IU- instead write international unit
(mistaken for IV or #10)
3)QD or QOD- write out every day or every other day
(mistaken for eachother or QID)
4)Trailing zero (X.0 mg) or lack of leading zero (.X mg) Instead write Xmg or 0.Xmg
(decimal point is missed)
5) MS and MS04 and MgSo4 instead write out morphine sulfate and magnesium sulfate
(mistaken for eachother)

Front 57

Goal 2C:
Critical results as a means to improving the effectiveness of communication among caregivers

Back 57

Must set up a system which defines what lab tests and results are critical and define an acceptable time for reporting

Front 58

Goal 2E: "hand off" communications as a means to improving the effectiveness of communication among caregivers

Back 58

S.B.A.R
Situation
Background
Assessment
Recommendation
plus time for Q&A

Front 59

Goal 3C: LASA meds as a way to improve the safety of using medications

Back 59

Identify and anually review a list of SALA drugs and take action to prevent interchange

Front 60

Examples of SALA drugs

Back 60

DOPAmine vs Dobutamine
Diazepam vs Ditropan
hydroxizine vs Hydralazine
Humulin vs Humalog
Novolin vs Novolog
Celexa vs Celebrex
Avandia vs Coumadin
Sertraline vs Seroquel
Topamax vs Toprol
Zyprexa vs Zyrtec

Front 61

NPSG Goal 3D: labeling as a way to improve the safety of using medications

Back 61

Label all meds, med containers, or other solutions on and off the sterile field
-Drug name, strength,amt, exp.
-Standardize the label
-Limit and standardize concentrations

Front 62

NPSG Goal 3E: Anticoagulation Safety as a way to improve the safety of using medications

Back 62

Implement a defined anti-coag program to individualize care
reduce compounding and labeling errors by using only unit dose oral and premixed infusions when possible.
-Warfarin is dispensed with extablished monitoring procedures
-protocols are appropriate
-Baseline and current INR's are drawn and available to adjust therapy
-dietary services are notified of at pts of warfarin
-Heparin IV on programmable infusion pumps
-Baseline and current labs for heparin pts
-educate heparin pts and family, including follow up issues
-org. evaluates anticoag safety practices

Front 63

NPSG Goal 7A: Hand hygeine to reduce the risk of healthcare associated infections

Back 63

WASH YOUR HANDS BEFORE AND AFTER ENTERING PATIENT ROOMS!

Front 64

NPSG Goal 7B: death due to hospital infection to reduce the risk of healthcare associated infections

Back 64

Manage all as Sentinel events when death or major loss of fxn assoc. with a health care associated infection.

Front 65

NPSG Goal 8A for medication reconciliation upon entrance

Back 65

process for comparing patients current medications from home with those ordered by the organization.
_complete list at entry/admission
-meds ordered are then compared to those on the list and discrepancies are resolved.

Front 66

NPSG Goal 8B- for medication reconciliation for exit

Back 66

A complete list is provided and communicated to the next provider of care when transferred
-Or a complete list is provided to the patient upon discharge

Front 67

NPSG Goal 9 to reduce the risk or patient harm resulting from falls

Back 67

Beer's Criteria- implement a fall reduction program and evaluate the effectiveness (Red Sox)

Front 68

NPSG Goal 10 to help with long term, disease-specific care

Back 68

develop and implement a protocol for administration and documentation of the flu and pneumococcus vaccine.
-Develop a protocol to identify new outbreaks and management of that outbreak.

Front 69

NPSG Goal 11

Back 69

reduce the risk of surgical fires

Front 70

NPSG Goal 13- for patient's active involvement

Back 70

Define and communicate the means for patients and families to report concerns about safety

Front 71

NPSG Goal 16- to improve recognition and response to changes in a patients condition

Back 71

select a method that enables staff to directly request additional assistance from specially trained individuals when a patient's condition seems to be worsening

Front 72

What is the National Quality Forum?

Back 72

A voluntary consensus and evidence based standards to identify ways to reduce error and improve patient care.

Front 73

NQF for Ventilator assoc pneumonia- 4 recommendations

Back 73

1. Elevate head of bed 30 degrees or more.
2. "sedation vacation" and asses for readiness to extubate.
3. Initiate PUD prophylaxis
4. Initiate DVT prophylaxis

Front 74

2 NQF recommendations to prevent surgical site infections

Back 74

1. appropriate AB use (1 hr prior and stop within 24 hours)
2. Tight Glucose control

Front 75

NQF's request to evaluate pt's undergoing elective surgery for risk of an acute ischemic perioperative cardia event

Back 75

1.those who require Beta Blockers to control angina sx's, w/ arrythmias, or HTN
and 2. Those at high risk due to findings of ischemia in preoperative testing and are undergoing vascular surgery.

Front 76

What is FMEA?

Back 76

Failure Mode and Effects Analysis
-A structured approach to identify ways in which a process can fail, estimating risks assoc, with specific causes and prioritizing actions that could be taken to reduce risk.
A PROACTIVE, TEAM-BASED, APPROACH

Front 77

7 Steps of FMEA

Back 77

1. Select a high risk process and assemble a team.
2. Diagram the process.
3.Brainstorm potential failures, why they might happen and determine their effects.
4. Rank the severity and prioritize
5. determine deeper causes of critical failure modes
6. Redesign a process where the effect of errors are unacceptable
7. Analyze, test, implement and monitor new process.

Front 78

Step 1
Select a high risk process and assemble a team.

What is important regarding selecting a team?

Back 78

They should be:
-close to the proscess
-critical to implementing changes
-credible and respected
-diverse knowledge base
-fewer than 10 members
They should then come up with a scope and a mission

Front 79

FMEA Step 4 Rank the severity and prioritize. How do we calculate hazard score?

Back 79

severity score X probability score = hazard score
severity score- severity of failure
probability score- likelihood of failure

Front 80

FMEA Step 5 Determine deeper causes

Back 80

Determine 5 levels of WHY???

Front 81

What is a Failure Mode?

Back 81

The way in which a component, product or process could fail to perform its intended function.
-may be the result of upstream operations of may cause downstream operations to fail

Front 82

3 questions you need to answer to be able to do a FMEA

Back 82

1. how likely is the equipment or process to fail?
2. What is the significance if it fails?
3. How likely will one be able to detect this failure?

Front 83

rating Scales for severity, Occurance and Detection

Back 83

1= not severe
10= very severe
1= not likely to occur
10= very likely to occur
1= likely to detect
10= not likely to detect

Front 84

What is a Root Cause Analysis? (RCA)

Back 84

A process for identifying contributing/causal factors that underlie variations in performance assoc. with ADVERSE EVENTS or CLOSE CALLS

Front 85

Where did RCA's come from?

Back 85

FMEA for US militry, NASA and auto industry

Front 86

What is a RCA Model?

Back 86

An analysis which identifies changes that can be made in systems thru either REDESIGN OR DEVELOPMENT OF NEW PROCESSES, EQUIPMENT OR APPROACHES that will REDUCE THE RISK of this event reoccuring or having a close call
-confidential
-legally protected

Front 87

What questions does the RCA model try to answer?

Back 87

What happened that day?
What usually happens?
What should have happened?
Why did it happen?
What are we going to do to prevent it from happening again?
How will we know that it worked?

Front 88

What are some of RCA's goals?

Back 88

to prevent, not punish
to build a culture of safety
to identify causes
to identify ways to prevent reocurrance
to measure and track outcomes