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76 Cards in this Set

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What is an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done?
error
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)?
Error
Is an error an act of commission or omission?
both commission and omission
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?
Adverse drug event
What term describes an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity or both?
adverse drug reaction
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?
medication error (National coordinating council for medication error reporting and prevention)
What term describes any preventable event that may cause or lead to inappropriate medication use or harm to a patient?
medication error (FDA)
What organization must sentinel events always be reported to?
MedWatch program
What term describes an unexpected occurance involving death or serious physical or psychological injury, or the risk thereof?
Sentinel event
What term describes an error which occurs as a result of an action not taken?
Error of omission
Do errors of omission always lead to adverse outcomes?
No, they may or may not lead to adverse outcomes
What term describes an error which occurs as a result of an action taken?
error of commission
Do errors of commission always lead to adverse outcomes?
No, they may or may not result in adverse outcomes
What are the five rights of medication therapy?
Right Patient, Right Drug, Right Dose, Right Route, Right Time
What are the five type of medication errors?
Wrong patient, wrong drug, wrong dose, wrong route, wrong time
What are the two types of wrong drug errors?
Wrong medication and concentration
What are possible causes of wrong drug errors?
LASA, bad handwriting, incorrect stocking of medication carts or dispensing systems, lack of knowledge of new drugs, choosing wrong "short code" from computer listing
What are the wrong dose error categories discussed in class?
Wrong concentration of drug, wrong infusion rate of IB, wrong tablet or capsule dose dispensed, wrong interpretation of orders
What are the four stages of a Medication Safety Initiative Model?
1. Environment / Culture Analysis
2. Data collection
3. Data analysis
4. Assessing impact of actions taken
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?
medication error
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?
errors in automatic mode or "slips"
What term describes an error produced by misjudging the situation, misapplying a rule, a conscious incorrect action?
rule-based mistakes
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?
Knowledge based mistakes
What error is produced by a skilled worker in a familiar activity that the mistake is made due to an automatic response to situation?
skill-based mistakes
What error is made by a rule-based mistake, knowledge based mistake, skill based mistake, availability bias, or conformational bias?
Errors in the Problem-solving mode or "mistakes"
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?
availability bias (heuristic)
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?
confirmation bias
What are the two classes of system errors?
active errors and latent errors
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)?
active errors
What is the term for the error in which the effects are delayed (ie accidents waiting to happen)?
latent errors
What does the stage one of Medication Safety Initiative model seek to understand?
The causes of errors through Enivronment and Culture analysis
What is the swiss cheese model?
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
What category of error exist when circumstance have the capacity to cause error but no error has occured?
Category A
What category of error exists when an error has occurred but did not reach the patient with an intervention before the medication was given?
Category B
What category of error exists when an error occurred, the error reached the patient, but the error caused not harm to the patient?
Category C
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?
Category D
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?
Category E
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?
Category F
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)?
Category G
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)
Category H
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?
Category I
What term describes a phase in the medication use process (prescribing, transcribing, dispensing, administering, monitoring) where the error occured?
Node
What term describes a particular kind of error (eg omission, wrong drug, improper dose, wrong patient)?
Type of error
What term associates an error with one or more particular reasons for the outcome that occurred?
Cause of the error
What is a pro-active tool that can be used to identify potential poroblems before harm can occur?
FMEA (Failure Mode and Effects Analysis)
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?
Root cause
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?
High alert medications
What term describes those medications that, if misused, could cause serious harmful consequences for the patient?
high alert medications
What system is part of the united states pharmacopeia and provides adverse drug event data analysis?
Medmarx system
What term describes actions that most likely to be sucessfull in accomplishing and sustaining the desired changes?
strong impact actions
What term describes actions that are likely to result in accomplishing and sustaining the desired change?
Intermediate Impact actions
What term describes action that may not result in the desired changes and/or are less likely to sustain the desired change?
Weak impact actions
What term describes where the risks occur?
Danger Zone
What term describes the events or conditions that occured immediately prior to the problem that was the direct cause of the problem (undesired outcome)?
proximate cause
What term describes one or more basic factors that lead to the proximate cause - the underlying cause of the problem observed?
Root cause
What term describes a method of analysis that serves to uncover the root causes of a problem?
RCA - Root Cause Analysis (retrospective approach)
What term describes a method of continuously asking why until the underlying cause of a problem is determined?
The five why's
What are the basic elements of RCA?
Materialsw, machine/equipment, environment, management and manpower, methods, management systems
What term describes a prospective method of recongnizing and addressing potential failures, identifying actions that could prevent negative outcomes, and clearly documenting the process?
Failure Mode and Effect Analysis (FMEA)
What term describes the systematic process of preventing failure before negative outcomes (harm) occurs?
Failure Mode and Effect Analysis (FMEA)
What is PDCA?
plan-do-check-act
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?
Organizational Culture
What term describes how we do things in our organization?
Organizational culture
What is organizational culture to a patient?
What the patient or caregiver sees, hears, or feels.
What term describes the shared commitment of management and employees to ensure the safety of the work environment?
culture of safety
What term describes the blameless approach to reporting that encourages reporting of errors?
The just culture
What are the categories of responsibility for medical errors?
human error, negligent conduct, reckless conduct, and intentional rule violations
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?
Human error
What term describes the failure to exercise skill, care, and learning expected of a reasonably prudent health care provider?
negligent conduct
What term describes the conscious disregard of a visible, significant risk?
reckless conduct
What term describes when an individual chooses to knowingly violate a rule while performing a task?
Intentional rules violation
Who is the second victim?
Healthcare worker that caused the mistake
What term describes a method for achieving a task or goal when the planned method isnt working correctly or efficiently?
workaround
What is best practice?
Enhance patient safety, efficient and timely and cost effective, uses a system wide approach, patient centered, effective, equitable, evidence based
What is best practice?
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
What are the six aims of the Institute of Medicine report of 2001?
Safem effective, patient centered, timely, efficient, and equitable