Medication Safety and Quality Improvement

A cardiologist at a major teaching hospital has requested that edoxaban be added to the formulary. The clinical pharmacy team and medication safety officer meet to discuss risks associated with adding another novel oral anticoagulant to the formulary. They brainstorm the potential for errors when the drug is ordered in the CPOE system, when it is filled in the pharmacy, when nurses administer it. They discuss the lack of an effective antidote and wonder if use of expensive Factor products may increase. After exploring potential areas for risk with this drug, they brainstorm strategies to reduce these known risks. When edoxaban is discussed at the P&T Meeting, the team will be prepared to request implementation of key risk reduction strategies. This is an example of which of the following: Answer A FMEA B Medication error reduction C Sentinel event predication D RCA E Drug utilization review (DUR)

A FMEA (Failure Mode Effects Analysis)

In a healthcare setting soap and water (as opposed to alcohol-based rubs) must be used to wash hands in the following situations: (Select ALL that apply.) Answer A When hands are visibly dirty B After caring for a patient with a C. difficile infection C Before using the rest room D After caring for a patient with irritable bowel syndrome E After caring for a patient with a Pseudomonas infection

AB The soap can be plain or antibacterial. Jewelry should be removed. IBS can be associated with constipation or diarrhea. The diagnosis of IBS alone does not warrant soap and water hand washing.

Any "high alert" drug, including insulin, can be placed in a brightly colored bin with warnings on the front. Items that should be dispensed with the drug, such as MedGuides or oral syringes, can be placed inside the bin. Warnings on the front of the bin could include alerts for name mix-ups, alerts to check mg/kg weight (if applicable), and other notices. Medications that are often mixed up should be physically separated in the pharmacy (not side-by-side on the shelf, for example).

ABC Use of single dose vials is preferable. If multi-dose vials are used, they should be assigned to a single patient and labeled. If the multi-dose vials are used for multiple patients, it is imperative that the needle/syringe is changed for each administration.

Choose options that may be present in a given community for patients to return used sharps (syringes and needle tips): (Select ALL that apply.) Answer A Pharmacies B Police and fire departments C Public drop boxes and mail boxes D Hazardous waste pick-up days or collection sites E Discarding in public waste bins that are present on city streets and at bus stops.

ABCD Wherever the patient is working, he/she will need to know where local residents are supposed to bring sharps. In many communities there exists residential hazardous waste pick-up where home users place the used sharps in a special "sharps" container and, much like a recycling container, it is set outside for pick-up by special waste handlers.

Many drug errors are due to look-alike names, such as Celebrex/Celexa, Zantac/Xanax, Aricept/Aciphex, and many others. What are ways to reduce errors associated with look-alike names? (Select ALL that apply.) Answer A Changing the drug names (by FDA or the manufacturer's initiative) if drug mix-ups have occurred. B Using "TALL Man" lettering, for example writing glipiZIDE and glyBURIDE to help avoid confusion between the two drugs. C Including both brand and generic names on the prescription. D Spelling out the drug name on a verbal order. E Putting the indication on the prescription.

ABCDE

Organizations that are involved in medication safety include the following: (Select ALL that apply.) Answer A The American Society of Health-System Pharmacists B The Joint Commission C The Institute for Safe Medication Practices D The Institute of Medicine, The Agency for Healthcare Research and Quality E The Food and Drug Administration

ABCDE

The Joint Commission identifies areas where significant lapses in patient safety exist, and then implements National Patient Safety Goals (NPSGs). These recommend specific measures that would reduce risk and improve safety. The Joint Commission has NPSGs in which of the following areas? (Select ALL that apply.) Answer A Improving the way antithrombotics are used B Improving the use of patient identifiers C Improving medication labeling in perioperative settings D Improving the timely reporting of critical lab results E Compliance with CDC hand hygeine guidelines

ABCDE

The Joint Commission recognizes that the inappropriate use of antithrombotics contributes to many incidents of avoidable patient harm. Which of the following methods can help avoid incorrect use of antithrombotics? (Select ALL that apply.) Answer A Require the use of protocols that include recommended dosing; any dosing outside the protocol recommendations must be justified and approved by a pharmacist. B Monitor INRs at baseline and at scheduled intervals, which should be indicated on the protocol. C Use programmable pumps for heparin (i.e., not gravity drips). D Educate patients and families on correct use of the medications. Involve dietary team when inpatients are involved. E Have a pharmacist monitor each patient taking warfarin daily to assess for drug interactions and appropriateness of dose.

ABCDE Antithrombotic agents contribute to a considerable number of adverse drug events and should be a constant area of vigilance for pharmacists and the rest of the healthcare team.

TV is a pediatric clinical pharmacist who specializes in medication use and dosing for very small patients. She is overseeing the emergency "crash cart" preparation for the neonatal unit. She advises the medical team on these safe practices for the crash carts: (Select ALL that apply.) Answer A The medications should be prepared in pre-filled syringes and drips, as much as possible. B The medications should be age and weight specific, as much as possible. C A weight-based dosing chart should be present in the crash cart. D The crash carts should be refilled by the nursing staff in the unit after a code. E Drug expiration dates should be frequently monitored.

ABCE

A prescriber wrote a prescription for "MS 1gram IV" for a patient. He wanted the patient to receive magnesium sulfate, but the patient received a fatal dose of morphine. Select the correct method to reduce this error in the future: (Select ALL that apply.) Answer A For morphine sulfate, do not write MS or MS04, write out morphine sulfate. B For magnesium sulfate, do not write MS or MgS04, write out magnesium sulfate. C Institute a tech check tech policy in the pharmacy. D Avoid abbreviations whenever possible. E If abbreviations are used they must be on an approved list at your institution.

ABDE Avoid abbreviations whenever possible. This alone would reduce the amount of medication errors considerably. If abbreviations are used they must be on the hospital's approved list. Do not use any abbreviations on the Joint Commission's "Do Not Use" list.

Dr. Davis wrote a prescription for a five year-old boy. The prescription was written: 1.0 teaspoonful of oral suspension. Use-as-directed. The pharmacist wanted to verify the dose, but neither the child's age nor weight was provided. What are possible sources of medication errors found in this prescription? (Select ALL that apply.) Answer A Using "as directed" for patient instructions B Not providing the route of administration C Using a "teaspoonful" to indicate the dose D Not providing the patient's weight to verify the dose, or the indication E Use of a trailing zero

ACDE Causes of prescribing errors include sloppy handwriting, missing indications (if the pharmacist knows the indication, they can check for proper use), inappropriate measurements (such as writing one teaspoon instead of 5 mL), not providing age and weight for liquids (especially with pediatrics and geriatrics), using trailing zeros (this could be misread as ten teaspoonfuls), and using "as directed."

Which of the following categories are considered high-alert medications? (Select ALL that apply.) Answer A Anticoagulants B Loop diuretics C Insulin D Sedatives E Opioids

ACDEInsulin is high risk (due to hypoglycemia), opioids (due to respiratory depression), anticoagulants (due to bleeding risk-or clot risk if under-dosed) and sedatives (due to risk of over-sedation, hypotension, delirium and respiratory depression). Loop diuretics are not without safety concerns, but they are not considered high-alert.

A hospital pharmacist is designing an inservice on the use of patient controlled analgesic (PCA) devices. She should include the following points in her presentation: (Select ALL that apply.) Answer A The need to assess pain, sedation and respiratory rate on a scheduled basis in all patients receiving opioids from a PCA. B Educate staff about morphine and hydromorphone mix-ups; morphine is much more potent than hydromorphone. C The requirement to have a close family member receive education on the use of the PCA in the event that the patient is sleeping and cannot self-administer a dose. D Not all patients may be appropriate candidates for PCAs. E Barcode technology may help reduce dosing errors associated with PCAs.

ADE Hydromorphone is about six times as potent as morphine. Friends and family members cannot give PCA doses; TJC does not permit it. In some cases (such as with neonates) there may be exceptions, but not in adults. Someone may be trying to knock-off Grandma to inherit her money. Or, a family member may not wish their loved one to suffer and consequently press the button too many times.

A hospital pharmacist dispensed the wrong vaccine for an infant, who then had to be re-inoculated. The same pharmacist pulled the wrong type of insulin from the refrigerator to send to the floor. Which of the following represents the most reasonable method to help the pharmacist avoid this type of error in the future? Answer A Indications for use on the prescription. B Placing the medications in high-risk bins, with notations on the front of the bins regarding name-mix-ups and other relevant alerts. C Having the pharmaceutical companies present more information on their drugs at grand rounds. D The use of standarized protocols. E Patient discharge education.

B Any "high alert" drug, including insulin, can be placed in a brightly colored bin with warnings on the front. Items that should be dispensed with the drug, such as MedGuides or oral syringes, can be placed inside the bin. Warnings on the front of the bin could include alerts for name mix-ups, alerts to check mg/kg weight (if applicable), and other notices. Medications that are often mixed up should be physically separated in the pharmacy (not side-by-side on the shelf, for example).

What is the name of the accreditation body for more than 18,000 health care organizations and programs in the U.S. including hospitals, health care networks, long term care facilities, home care organizations, office-based surgery centers and independent laboratories? Answer A Institute of Medicine B The Joint Commission C Institute for Safe Medication Practices D National Institutes of Health E Food and Drug Administration

B The Joint Commission (TJC) is an independent, not-for-profit organization. The goal of the Joint Commission is to improve health care for the public by evaluating health care organizations.

A pharmacist has entered a patient's room to check on the volume left in the PN bag. Upon leaving the room, she uses an alcohol-based hand rub. Which of the following statements are true concerning alcohol-based hand rubs? (Select ALL that apply.) They should be avoided in healthcare settings. B The alcohol hand rubs are germicidal against many gram positive and gram negative bacteria, including MRSA. C The alcohol hand rubs do not kill or remove Clostridium difficile. D Unless the hands are visibly soiled (or the person has used the restroom or eaten or cared for a person with diarrhea) the alcohol hand rubs do a better job of killing most organisms. E They should not be used more than twice daily.

BCD The alcohol-based hand rubs are in general, more effective, and do not dry the hands as soap can. They should be used when the hands are not visibly soiled, before putting on gloves, after contact with a patient if the hands are not visibly soiled and after removing the gloves. They do not kill spore-forming bacteria like C. difficile.

Dr. Davis makes a lot of mistakes, but his patients like him because he is old and friendly. KS is a pharmacist who fills a lot of prescriptions written by Dr. Davis. Whenever KS dispenses a new prescription to one of his patients (or to any other), she counsels the patient. KS understands that the use of patient counseling has these benefits: (Select ALL that apply.) Answer A Counseling ensures that the drug will cure the patient's condition. B Counseling can ensure that the patient is aware of monitoring required for the drug, since the prescriber might not order the proper monitoring tests. C Counseling can ensure the patient is aware of safety concerns with the use of the drug. D Counseling makes the patient aware of treatment goals; the patient should be assisting in determination of the drug's efficacy. E Counseling can ensure that the patient is getting a drug for their condition (and not for a wrong indication, or for a wrong patient.)

BCDE An educated patient will often know if the drug is not working, if it's toxic, and if, by chance, they are given the wrong medication. The more the patient knows, the more equipped they will be to help reduce the risk of medication errors and increase medication efficacy and safety. The majority of dispensing errors are not detected by the pharmacist during the final check but are detected during counseling. Counseling protects patients and the pharmacist.

The Emergency Department has had 3 errors in the past 4 months involving hypertonic saline for traumatic brain injury (TBI). What measures can the hospital take to improve use of this high-risk medication? (Select ALL that apply.) Answer A Move all hypertonic saline to the ADC in the Emergency Department. B Develop a protocol for use of hypertonic saline in TBI. C Stock only premixed IV products. D Allow ED staff to prepare the hypertonic saline, since they are most familiar with its safe use. E Stock the minimum number of product options/strengths.

BCE

The Joint Commission sets goals each year to improve patient safety. These include reducing the incidence of health-care associated infections (such as catheter infections, IV line infections, pneumonia from ventilators, etc.), maintaining accurate patient information (including conducting medication reconciliation, and providing information to patients, such as discharge counseling on their medications before they leave the facility), and others. What is the name of these goals? Answer A Centers for Improved Care Recommendations (CICRs) B Safety Development Techniques (SDTs) C National Patient Safety Goals (NPSGs) D Patient and Provider Minimum Criteria (PPMCs) E Joint Commission Facility Safety Goals (JCFSGs)

C

What is the term used to describe the tendency of healthcare providers to override computerized alerts because they perceive them to be irrelevant, impractical or too numerous? Answer A Alert avoidance B Alert boredom C Alert fatigue D Warning sign E Decision avoidance

C Alert fatigue is a major problem in the computerized healthcare environment. Systems should be are designed with alerts to protect and assist providers. When the alerts are not useful (or not perceived to be useful) healthcare providers may begin to just override (ignore) the alert.

A pharmacist is completing a drug use evaluation (DUE) review for the physicians in the cardiology group. Choose the correct statement concerning DUEs: Answer A DUEs are not used frequently since prescribing is directed by guidelines in most practice settings. B DUEs do not help with patient safety, but they can be used to cut expenses. C DUEs are retrospective analyses of patient drug usage, or of physician prescribing habits. They can be helpful in guiding therapy to guidelines, or in saving money, or both. D DUEs are used solely to match prescribing to formulary restrictions. E DUEs involve a prospective analysis, but can occasionally be done via a retrospective analysis.

C DUEs are retrospective analyses of patient drug usage, physician prescribing and/or pharmacy dispensing activities. They can be used to identify problems or lapses that can be targeted for interventions.

Which of the following are High-Alert drugs per ISMP? Answer A Hypertonic saline and fosphenytoin B Vancomycin and potassium chloride injection C Potassium chloride injection and hypertonic saline D Vancomycin and gentamicin E Insulin and 0.45% sodium chloride

C Potassium chloride injection and hypertonic (3%) saline are High-Alert medications per ISMP.

What is a sentinel event? Answer A When medication errors in an institution fall below the national threshold or 1% of hospital admissions. B When medication errors in an institution rise above the national threshold or 10% of hospital admissions. C An unexpected occurrence involving death or serious physical or psychological injury or risk thereof. D A expected occurrence resulting in serious physical injury or risk thereof based on a drug interaction of adverse effect. E The action or event that would have prevented serious physical injury if it had been performed.

C Sentinel events often refer to a death in the institution, but the definition is more broad.

A pharmacist recently switched jobs as a result of a medication error that he made. He has supportive management who will support him as he identifies similar situations that led to the previous prescribing error and implements approaches that can help reduce errors. What is the name of the analysis done prospectively that can identify pathways that lead to errors and find ways to help prevent future errors? Answer A Root Cause Analysis B Prospective Error Search (PES) C Safety First Approach D Failure Modes and Effects Analysis (FMEA) E Prevention and Safety Analysis

D Failure modes and effects analysis (FMEA) is a step-by-step approach for identifying all possible ways in which something might fail. FMEA is used in different industries. In pharmacy, it is used to reduce medication errors.

Clinical pharmacists who work in Medication Therapy Management (MTM) programs use the prescription database to check that if a patient has certain diagnostic codes (ICD-10 codes), they are using medications appropriate for that condition, as certain medications reduce mortality or disease risk associated with certain conditions. Which of the following conditions is not matched with a drug that reduces mortality or risk associated with the condition? Answer A Heart failure - beta blocker B Diabetes with renal disease and/or hypertension - ACE inhibitor or ARB C Chronic high-dose steroids - bisphosphonate D S/P cerebrovascular accident - calcium channel blocker E Rheumatoid arthritis - methotrexate/other DMARD

D Patients who have had a CVA should be taking antiplatelet therapy for secondary prevention.

A pharmacist dispensed the wrong drug to a patient. His pharmacy manager screamed at him in front of the staff. The pharmacist got scared and quit. What is the preferred approach when a medication error has occurred? Answer A Conducting a behavorial intervention with the staff. B Hiring more technicians to perform double checks on all prescriptions. C Conducting a Failure Mode and Effects Analysis. D Punishing everyone involved with demotion or firings. E Conducting a root cause analysis.

E It would be preferable to figure out what really caused the error to occur and removing the causative factors so that the situation does not repeat. This is referred to as Root Cause Analysis, which means finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms.