Medication Safety Exam 1

Front 1

What is an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done?

Back 1

error

Front 2

What term describes the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning)?

Back 2

Error

Front 3

Is an error an act of commission or omission?

Back 3

both commission and omission

Front 4

What term describes any incident in which the use of a medication (drug or biologic) at any dose, a medical device, or a special nutritional product (for example dietary supplement, infant formula, or medical food) may have resulted in an adverse outcome in a patient?

Back 4

Adverse drug event

Front 5

What term describes an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity or both?

Back 5

adverse drug reaction

Front 6

What term describes any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer?

Back 6

medication error (National coordinating council for medication error reporting and prevention)

Front 7

What term describes any preventable event that may cause or lead to inappropriate medication use or harm to a patient?

Back 7

medication error (FDA)

Front 8

What organization must sentinel events always be reported to?

Back 8

MedWatch program

Front 9

What term describes an unexpected occurance involving death or serious physical or psychological injury, or the risk thereof?

Back 9

Sentinel event

Front 10

What term describes an error which occurs as a result of an action not taken?

Back 10

Error of omission

Front 11

Do errors of omission always lead to adverse outcomes?

Back 11

No, they may or may not lead to adverse outcomes

Front 12

What term describes an error which occurs as a result of an action taken?

Back 12

error of commission

Front 13

Do errors of commission always lead to adverse outcomes?

Back 13

No, they may or may not result in adverse outcomes

Front 14

What are the five rights of medication therapy?

Back 14

Right Patient, Right Drug, Right Dose, Right Route, Right Time

Front 15

What are the five type of medication errors?

Back 15

Wrong patient, wrong drug, wrong dose, wrong route, wrong time

Front 16

What are the two types of wrong drug errors?

Back 16

Wrong medication and concentration

Front 17

What are possible causes of wrong drug errors?

Back 17

LASA, bad handwriting, incorrect stocking of medication carts or dispensing systems, lack of knowledge of new drugs, choosing wrong "short code" from computer listing

Front 18

What are the wrong dose error categories discussed in class?

Back 18

Wrong concentration of drug, wrong infusion rate of IB, wrong tablet or capsule dose dispensed, wrong interpretation of orders

Front 19

What are the four stages of a Medication Safety Initiative Model?

Back 19

1. Environment / Culture Analysis
2. Data collection
3. Data analysis
4. Assessing impact of actions taken

Front 20

What term describes any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care profession, patient, or consumer?

Back 20

medication error

Front 21

What term describes errors that ressult from distraction, failure to pay attention, physiological causes like fatigue or sleep loss or alochol or drugs or illness, or phychological causes like busyness or boredom or frusturation or anxiety or anger?

Back 21

errors in automatic mode or "slips"

Front 22

What term describes an error produced by misjudging the situation, misapplying a rule, a conscious incorrect action?

Back 22

rule-based mistakes

Front 23

What term describes an error produced when the problem solver faces a situation for which they have no experience or limited knowledge, infrequently used skills, or incorrectly applying a protocol?

Back 23

Knowledge based mistakes

Front 24

What error is produced by a skilled worker in a familiar activity that the mistake is made due to an automatic response to situation?

Back 24

skill-based mistakes

Front 25

What error is made by a rule-based mistake, knowledge based mistake, skill based mistake, availability bias, or conformational bias?

Back 25

Errors in the Problem-solving mode or "mistakes"

Front 26

What term describes the error caused by the tendency to focus on the first answer that occurs to the individual, staying with the first answer despite evidence that it is wrong, or making a decision based on what we remember instead of complete data?

Back 26

availability bias (heuristic)

Front 27

What term describes the error made by the tendency to accept evidence that confirms a person's own beliefs or conclusions, a failure to explore solutions that don't support one's own beliefs?

Back 27

confirmation bias

Front 28

What are the two classes of system errors?

Back 28

active errors and latent errors

Front 29

What is the term for the error in which the cause is easy to see and is immmediate (ie dispensed wrong drug, pushed wrong button)?

Back 29

active errors

Front 30

What is the term for the error in which the effects are delayed (ie accidents waiting to happen)?

Back 30

latent errors

Front 31

What does the stage one of Medication Safety Initiative model seek to understand?

Back 31

The causes of errors through Enivronment and Culture analysis

Front 32

What is the swiss cheese model?

Back 32

Each hazard in drug therapy has defenses but each defense has gaps in the defenses. Together the defenses provide a mesh to keep the errors from causing an adverse drug event. Unfortunately, sometimes the holes in the mesh align and give an adverse drug event

Front 33

What category of error exist when circumstance have the capacity to cause error but no error has occured?

Back 33

Category A

Front 34

What category of error exists when an error has occurred but did not reach the patient with an intervention before the medication was given?

Back 34

Category B

Front 35

What category of error exists when an error occurred, the error reached the patient, but the error caused not harm to the patient?

Back 35

Category C

Front 36

What category of error exist when an error occurred, the error reached the patient, additional monitoring was required to confirm the error caused no harm to the patient or an intervention was required to prevent harm to the patient?

Back 36

Category D

Front 37

What category of error exists when an error occured, the error reached the patient, the error may have contributed to or resulted in temporary harm to the patient, and the patient required intervention after the error?

Back 37

Category E

Front 38

What category of error exists when an error occurred, the error reached the patient, the error may have contributed to or resulted in temporary harm to the patient, the patient required initial or prolonged hospitalization due to the error, and the patient requires transfer to a higher level of service such as intensive care?

Back 38

Category F

Front 39

What category of error exists when an actual error occurs, the error reached the patient, the error may have contributed to or resulted in PERMANENT harm to the patient (permanent harm meaning permanent loss of physical and/or emotional function)?

Back 39

Category G

Front 40

What category of error exists when an error occurs, error reaches the patient, the patient requires intervention to sustain life? (the intervention required is vital and/or heroic, without this intervention the patient would die, however the patient fully recovers)

Back 40

Category H

Front 41

What category of error exists when an error occurs, the error reaches the patient, and the error may have contributed to or resulted in the patients death?

Back 41

Category I

Front 42

What term describes a phase in the medication use process (prescribing, transcribing, dispensing, administering, monitoring) where the error occured?

Back 42

Node

Front 43

What term describes a particular kind of error (eg omission, wrong drug, improper dose, wrong patient)?

Back 43

Type of error

Front 44

What term associates an error with one or more particular reasons for the outcome that occurred?

Back 44

Cause of the error

Front 45

What is a pro-active tool that can be used to identify potential poroblems before harm can occur?

Back 45

FMEA (Failure Mode and Effects Analysis)

Front 46

What term describes a retrospective approach to figuring out what caused am error, digging deep to find the "root cause", considers multidisciplinary issues contributing to the probleM?

Back 46

Root cause

Front 47

What term describes those medications that are involved in a high percentage of errors and/or sentinel events and/or carry a higher risk for abuse, errors, or other adverse outcomes?

Back 47

High alert medications

Front 48

What term describes those medications that, if misused, could cause serious harmful consequences for the patient?

Back 48

high alert medications

Front 49

What system is part of the united states pharmacopeia and provides adverse drug event data analysis?

Back 49

Medmarx system

Front 50

What term describes actions that most likely to be sucessfull in accomplishing and sustaining the desired changes?

Back 50

strong impact actions

Front 51

What term describes actions that are likely to result in accomplishing and sustaining the desired change?

Back 51

Intermediate Impact actions

Front 52

What term describes action that may not result in the desired changes and/or are less likely to sustain the desired change?

Back 52

Weak impact actions

Front 53

What term describes where the risks occur?

Back 53

Danger Zone

Front 54

What term describes the events or conditions that occured immediately prior to the problem that was the direct cause of the problem (undesired outcome)?

Back 54

proximate cause

Front 55

What term describes one or more basic factors that lead to the proximate cause - the underlying cause of the problem observed?

Back 55

Root cause

Front 56

What term describes a method of analysis that serves to uncover the root causes of a problem?

Back 56

RCA - Root Cause Analysis (retrospective approach)

Front 57

What term describes a method of continuously asking why until the underlying cause of a problem is determined?

Back 57

The five why's

Front 58

What are the basic elements of RCA?

Back 58

Materialsw, machine/equipment, environment, management and manpower, methods, management systems

Front 59

What term describes a prospective method of recongnizing and addressing potential failures, identifying actions that could prevent negative outcomes, and clearly documenting the process?

Back 59

Failure Mode and Effect Analysis (FMEA)

Front 60

What term describes the systematic process of preventing failure before negative outcomes (harm) occurs?

Back 60

Failure Mode and Effect Analysis (FMEA)

Front 61

What is PDCA?

Back 61

plan-do-check-act

Front 62

What term describes a pattern of basic assumptions that are invented, discovered, or developed by a group as it learns to cope with the problems which have evolved over time and are handed down from one generation to the next?

Back 62

Organizational Culture

Front 63

What term describes how we do things in our organization?

Back 63

Organizational culture

Front 64

What is organizational culture to a patient?

Back 64

What the patient or caregiver sees, hears, or feels.

Front 65

What term describes the shared commitment of management and employees to ensure the safety of the work environment?

Back 65

culture of safety

Front 66

What term describes the blameless approach to reporting that encourages reporting of errors?

Back 66

The just culture

Front 67

What are the categories of responsibility for medical errors?

Back 67

human error, negligent conduct, reckless conduct, and intentional rule violations

Front 68

What term describes when there is general agreement that the individual should have done other than what they did and in the course of that conduct inadvertently cause or could cause an undesirable outcome with the individual labeled as having committed an error?

Back 68

Human error

Front 69

What term describes the failure to exercise skill, care, and learning expected of a reasonably prudent health care provider?

Back 69

negligent conduct

Front 70

What term describes the conscious disregard of a visible, significant risk?

Back 70

reckless conduct

Front 71

What term describes when an individual chooses to knowingly violate a rule while performing a task?

Back 71

Intentional rules violation

Front 72

Who is the second victim?

Back 72

Healthcare worker that caused the mistake

Front 73

What term describes a method for achieving a task or goal when the planned method isnt working correctly or efficiently?

Back 73

workaround

Front 74

What is best practice?

Back 74

Enhance patient safety, efficient and timely and cost effective, uses a system wide approach, patient centered, effective, equitable, evidence based

Front 75

What is best practice?

Back 75

a technique, method, process, activity, incentive, or reward that is believed to be more effective at delivering a particular outcome than any other technique, method, process

Front 76

What are the six aims of the Institute of Medicine report of 2001?

Back 76

Safem effective, patient centered, timely, efficient, and equitable