Medication Safety -L1

Front 1

Discuss the history and evolving culture of medication safety

Back 1

Safety was not Job #1 .

Front 2

How the culture of safety in healthcare differs from the culture in highly reliable industries?

Back 2

-rely on personalized reporting
-system not designed for safety(non creative)
-does not commit to continual safety improvements(not routine)
-silos
-process stagnation

Front 3

Name Ineffective Approaches to Medication Error Prevention

Back 3

-Naming ,blaming, shaming and training
-practitioners “redefine” errors

Front 4

Fail-safe system

Back 4

-safeguarding the event of failure
-does not mean unable to fail but the devise will do whatever possible to minimize the negative effect when it happens

Front 5

Describe Effective Approaches to Medication Error Prevention

Back 5

-Focus attention on System
-Redefine accountability
-Make MORE people MORE accountable(Shared accountability)
-Proactive not reactive
-Promotes open communication about errors

Front 6

Key concepts in safeguarding high alert medications(Part I)

Back 6

Simplify - reduce steps and number of options
Externalize or centralize error prone processes
Differentiate items (appearance, location)
Differentiate items (touch, color, smell, etc.)
Standardize (communication and dosing methods)
Redundancy (check systems, back-ups)

Front 7

Key concepts in safeguarding high alert medications(Part II)

Back 7

Reminders
Improved access to information
Use of constraints that limit access or use
Forcing functions
Failsafes
Use of defaults
Failure analysis for new products and procedures

Front 8

The Three Behaviors towards making errors

Back 8

Console(Human error )-Product of current system designs
Coach(At-risk behavior )-Unintentional risk taking
Punish(Reckless behavior )-Intentional risk taking

Front 9

managed through remedial /disciplinary action

Back 9

Reckless behavior -Intentional risk taking

Front 10

Identify the mispaired Reporting Systems
Internal Paper forms:Internal
ISMP-MERP:External
AHRQ:Patient Safety Organization(PSO)
Hotlines:External

Back 10

Hotlines:External

Front 11

Errors that were intercepted and corrected before reaching the patient/consumer.

Back 11

Near Mises

Front 12

Errors that do not result in any change in treatment or transfer of patient to a higher level of care

Back 12

Errors with No Harm

Front 13

Includes errors that result in any change in treatment or care level

Back 13

Errors with Harm

Front 14

Seven elements of the medication-use process that cause medication errors

Back 14

SSOPAMP

Front 15

process for identifying the basic or causal factor(s) that underlie variation in performance

Back 15

Retrospective (What,Why,and How?)

Front 16

The Joint Commission allows entry to the pharmacy by non-pharmacy personnel when the pharmacy is closed

Back 16

False

Front 17

What is the main cause of dispensing errors according to Pharmacists

Back 17

Workload

Front 18

Periods of low workload may increase the risk of error

Back 18

True

Front 19

Identify the wrong staement.
1.Pharmacists with training in stress management made fewer errors.
2.Pharmacists with supervisors who promote autonomy made fewer errors.
3.Pharmacists who receive constructive feedback about their errors were better able to detect subsequent errors.
4.None

Back 19

4

Front 20

Computerized prescribing can also be a source of error.

Back 20

True

Front 21

When labelling a Syringe and admixture labels,the drug name should be highlighted and the brand name in parenthesis

Back 21

False.
drug name must be in bold not highlighted

Front 22

Many facilities use an armband to indicate that a patient has an allergy.

Back 22

True

Front 23

Room number is an acceptable identifier in addition to another identifier.

Back 23

False

Front 24

All medication orders should be sent to the Pharmacy (e.g. ED orders even if the medication is not supplied by Pharmacy, diet orders

Back 24

True

Front 25

Nurses are more affected by distractions than physicians or pharmacists.

Back 25

True

Front 26

Institute of Medicine recommends that nurses work nor more than 12 hours per da or 60 hours per week.

Back 26

True

Front 27

List problematic medications

Back 27

heparin (and other IV anticoagulants)
insulin
Concentrated insulin (U-500)
Concentrated oral morphine solutions (20mg/ml)
Sterile water for injection large volume parenteral (1000ml)
Neuromuscular blocking agents
Multidose vials