Chapter 76: Medication Safety & Quality Improvement

Front 1

What are the two organizations actively involved in improving medication safety?

Back 1

The joint commission (TJC) and the Institute for Safe meditation practices (ISMP)

Front 2

What is the formal definition of a medication error?

Back 2

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.

Front 3

What is the difference between medication errors adverse drug reactions (ADR)?

Back 3

ADRs are generally not avoidable, although they may be more likely to occur if the drug is given to patient at high-risk for certain complications

Hint 3

Front 4

What is a sentinel event?

Back 4

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof

Front 5

What is the most common cause of medication error?

Back 5

A problem with the design of the medical system itself

Front 6

For each section what are the at risk behaviors compromise patient safety?

Drug and patient related:

Communication:

Technology:

Working environment:

Back 6

Back (Definition)

Front 7

What is an error of omission versus an error of commission?

Back 7

Back (Definition)

Front 8

In the hospital setting, which two committees inside of the hospital should be informed of error when reporting an error?

Back 8

Pharmacy and therapeutics committee (P&T) and Medication safety committee

Front 9

What organizations specialize in error prevention?

Back 9

Medication Errors Reporting Program (MERP)

Front 10

What is the Medication Errors Reporting Program (MERP) and what does it do?

Back 10

Confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and provides recommendations for prevention

Front 11

Where should medication errors and close calls be reported?

Back 11

On the ISMP website (www.ismp.org)

Front 12

What is a root cause analysis (RCA)? What is a failure mode and effects analysis (FMEA)?

Back 12

Back (Definition)

Front 13

What is the joint commission on accreditation of healthcare organizations (TJC)?

Back 13

Back (Definition)

Front 14

Who sets the national patient safety goals? How often are these goals set?

Back 14

Annually by the joint commission (TJC)

Front 15

What does the NPSG 03.05.01: reduce the likelihood of harm associated with anticoagulant therapy, entail?

Back 15

Back (Definition)

Front 16

What does NPSG 03.06.01: maintain and communicate accurate patient medication information, entail?

Back 16

Back (Definition)

Front 17

What does NPSG 07.03.01;07.04.01;07.05.01;07.06.01: implement evidence-based practices to reduce healthcare associated infections, entail?

Back 17

Back (Definition)

Front 18

Describe what each of the following national patient safety goals, entail:

01.01.01

02.03.01

03.04.01

03.05.01

03.06.01

07.07.01

Back 18

Back (Definition)

Front 19

Why should abbreviations not be used? What abbreviations are on the minimum list per TJC? Who also publishes a list of error prone abbreviations, symbols, and dosage designations?

Back 19

Abbreviations are unsafe and contribute to many medical errors.

ISMP

Front 20

What are tall man letters and when should they be used?

Back 20

Tall man lettering should be used for look-alike sound-alike medications. It’s a mix of upper and lower case letters drawing attention to the dissimilarities in the drug names.

Front 21

What drugs should be designated as high-alert?

Back 21

Trucks with a heightened risk of causing significant patient harm if used in error

Front 22

What are some ways high-alert medications can be used to safely?

Back 22

Using premixed products, limiting concentrations available in the institution, and stocking high alert products only in the pharmacy

Front 23

What are some examples of safe use precautions for insulin and for potassium?

Back 23

Back (Definition)

Front 24

What is medication therapy management? What do these reviews do?

Back 24

Back (Definition)

Front 25

What is medication reconciliation? Why is it done?

Back 25

Back (Definition)

Front 26

When should medication reconciliation be done?

Back 26

Back (Definition)

Front 27

T/F: It is never okay to use the term “as directed” on prescriptions.

Back 27

True!

Instead you might use “use per instructions on the dosing calendar”

Front 28

What system is used to measure?

Back 28

Metric system

Measurements should be recorded in the metric system only.

Front 29

T/F: Emergency medications/crash cart medications should be unit dose and age-specific.

Back 29

True!!

Front 30

What is a code blue?

Back 30

Back (Definition)

Front 31

What is computerized physician/provider order entry (CPOE)?

Back 31

Is a computerized process that allows direct entry of medical orders by prescribers

Front 32

T/F: Combination of CPOE and clinical decision support (CDS) has greater benefit. Clinical guidelines and patient labs can be built into the CPOE system and alerts can notify the prescriber if the drug is inappropriate or if labs indicate that the drug could be unsafe.

Back 32

True

Front 33

What is the most important medication error reduction tool available right now?

Back 33

Barcoding

Front 34

What does the barcode to do? When is it used?

Back 34

Back (Definition)

Front 35

What are some common names of automated dispensing cabinets?

Back 35

Pyxis, Omnicell, ScriptPro, and AccuDose

Front 36

T/F: The joint commission (TJC) requires that pharmacists review the order before the medication can be removed from the automated dispensing cabinets for a pt, even in special circumstances (an override).

Back 36

False!!

The joint commission (TJC) requires that pharmacists review the order before the medication can be removed from the automated dispensing cabinets for a pt, except in special circumstances (an override).

Front 37

What is used to improve automated dispensing cabinet safety?

Back 37

Barcode scanning

Front 38

What are some medications that should not be put into the automated dispensing cabinet (ADC)?

Back 38

Insulin, warfarin, and high-dose narcotics

Front 39

Why may Opioids be used with patient controlled analgesia (PCA)?

Back 39

To allow the patient to treat pain quickly.

Front 40

T/F: Friends and family members may administer PCA doses.

Back 40

False!

Friends and family members should not administer PCA doses. This is a TJC requirement.

Front 41

What are some PCA safety steps?

Back 41

Back (Definition)

Front 42

What are some common types of hospital acquired (nosocomial) infections?

Back 42

Back (Definition)

Front 43

Contact precautions are recommended for patients colonized or infected with what?

Back 43

MRSA, VRE, and C.difficile

Front 44

Airborne precautions are recommended for patients with what?

Back 44

Active pulmonary tuberculosis, measles, or varicella virus (chickenpox)

Front 45

What are some ways to prevent catheter related bloodstream infections?

Back 45

Back (Definition)

Front 46

T/F: Alcohol-based hand rubs are considered more effective in the healthcare setting than plain soap or anti-microbial soap and water.

Back 46

True

Front 47

What do antimicrobial hand soaps contain?

Back 47

Chlorhexidine

(Hibiclens)

Front 48

What are some situations in which you would use soap and water not alcohol-based rubs?

Back 48

Back (Definition)

Front 49

What are some safe injection practices for healthcare facilities?

Back 49

Back (Definition)