Medication Safety & Quality Improvement
An accredited organizations must undergo on-site survey by TJC at least every _____ and surveys can be unannounced.
3
What is the most common cause of medication errors?
A problem with the design of the medical system
Droplet precautions are recommended for patients with what?
Active B. pertussis Influenza virus Respiratory syncytial virus (RSV) Adenovirus Rhinivirus N. meningitidis Group A strep
Airborne precautions are recommended for patients with what?
Active pulmonary TB Measles Varicella virus
______ precautions are intended to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air.
Airborne
What are high-alert medications?
Anesthetics, IV or inhaled Antiarrhythmics Anticoagulants/antithrombotics Chemotherapeutics Epidural/intrathecal drugs Hypertonic saline Immunosuppressants Inotropics Insulins Magnesium sulfate Opioids Oral hypoglycemics Parenteral nutrition Potassium chloride and phosphates for injection Sterile water for injection
______ may be the most important medication error reduction tool available right now.
Barcoding
Soap and water hand washing should be used over alcohol-based rubs in what situations?
Before eating After using the restroom Anytime there is visible soil After caring for a patient with diarrhea or known C.diff Before caring for patients with food allergies
Hand hygiene should be performed when?
Before entering and after leaving patient rooms Before donning and after removing gloves Before handling invasive devices After coughing or sneezing Before handling food or oral medication
______ is computerized process that allows direct entry of medical orders by prescribers.
Computerized physician/provider order entry (CPOE)
_____ precautions are intended to prevent transmission of infectious agents which are spread by direct and indirect contact with the patient and the patient's environment.
Contact
What are the three categories of transmission-based precautions defined by the CDC?
Contact Droplet Airborne
What makes a patient an appropriate candidate for a PCA?
Cooperative Cognitive assessment is passed
Multiple dose vials pose the risk for what?
Cross-contamination (infection) Over-dosing
What are the 5 steps of medication reconciliation?
Develop a list of current medications Develop a list of medications to be prescribed Compare the medications on the two lists Note discrepancies and make clinical decisions based on the comparison Communicate the new list to appropriate caregivers and to the patients
What procedures allow high alert medications to be used safely?
Developing protocols or order sets for use Using pre-mixed products whenever possible Limiting concentrations available in institution Stocking high-alert products only in the pharmacy
What is on the minimum list of "Do Not Use" from the TJC standards?
Do not use: U, u (unit) IU Q.D., QD, q.d., qd Q.O.D., QOD, q.o.d., qod Trailing zero's Lack of leading zero MS MSO4 and MgSO4
______ precautions to prevent transmission of pathogens spread through close respiratory contact with respiratory secretions.
Droplet
What does FMEA stand for?
Failure Mode and Effects Analysis
______ is a proactive method used to reduce the frequency and consequences of errors. It analyzes the design of the system in order to evaluate the potential for failures and to determine what potential effects could occur when the medication delivery system changes in any substantial way or if a potentially dangerous new drug will be added to formulary.
Failure mode and effects analysis (FMEA)
What are drug and patient related at risk-behaviors that can compromise patient safety?
Failure to check/reconcile home mediations and doses Dispensing medications without complete knowledge of the medication Not questioning unusual doses Not checking verifying allergies
T/F: Alcohol-based hand rubs are effective against C.diff (spores).
False (are not)
T/F: The contents of a sharps container can be pressed down to provide more room in the container.
False (cannot)
T/F: You can administer oral solutions/suspensions intravenously.
False (cannot)
T/F: Insulin can be placed in automated dispensing cabinets.
False (do not, all orders should be verified by pharmacists prior to dispensing)
T/F: Using the term "as directed" is acceptable on prescriptions as the doctor has told the patient how to use the medication.
False (patients often do not know and pharmacists cannot verify dosing regimen)
T/F: You should recap needles before disposing.
False (should not)
T/F: You should detach a disposable needle from original syringe when disposing of the needle.
False (throw entire assembly into sharps container)
What is the TJC requirement regarding PCA use?
Friends and family should not administer PCA doses
The most common error associated with automated dispensing cabinets is what?
Giving the wrong drug to the wrong patient
If an FDA sharps container is not available, patients can use what as an alternative?
Heavy-duty plastic household container with a lid (ex. plastic laundry detergent)
Brand name of chlorhexidine?
Hibiclens
Drugs with a heightened risk of causing significant patient harm if used in error should be designated as ______.
High-alert
What options may be present in the community for patients to dispose of hazardous waste/sharps?
Hospital/Pharmacy Police or fire station Household hazardous waste collection sites Mail-back programs Residential special waste services pick-up
The _______ is a confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and provides recommendations of prevention.
ISMP National Medication Errors Reporting Program (MERP)
Medication errors and close calls can be reported on ______ even if the error was reporting internally.
ISMP website
What medications should not be places into automated dispensing cabinets?
Insulin Warfarin High-dose narcotics
Institutions should have a plan in place for responding to medication errors and should address what 5 things about the error?
Internal notification External notification Disclosure Investigation Improvement
Protocols should be used for ____ delivery which includes which indications for IV administration, max infusion rate, max allowable concentration, guidelines for cardiac monitoring, infusions must be given via a pump, and prohibition of multiple simultaneous solutions.
KCl
What are the core elements of the NPSG 03.04.01:Improve the safety of using medications?
Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings Numerous errors have been associated with removing medications from original containers and placing them into unlabeled containers
What should be done to ensure PCA safety?
Limit opioids available in floor stock Use standard order sets so drugs are not over-dosed Educate staff Implement PCA protocals Use barcoding technology Assess patient's pain, sedation, and respiratory rate on scheduled basis
ISMP publishes a list of ______, _____, and _______ to help prevent errors.
List of error-prone abbreviations Symbols Dosage designations
________ medications are a common cause of medication errors.
Look-alike, sound-alike
Contact precautions are recommended for patients colonized or infected with _____ and ______ and patients with ____.
MRSA VRE C.diff
What does MERP stand for?
Medication Errors Reporting Program
______ is 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.
Medication error
What types of events should be reported?
Medication errors Preventable adverse drug reactions Hazardous conditions "Close calls" Near misses
Medication reconciliation is done to avoid _____.
Medication errors (omissions, duplications, dosing errors, or drug interactions)
______ involves comparing a patient's medication orders to all of the medications that a patient has been taking.
Medication reconciliation
What are the core elements of the NPSG 03.06.01: maintain and communicate accurate patient medication information?
Medication reconciliation Providing written information to patient Conducting discharge counseling (medication name, dose, frequency, route and indication at the minimum should be confirmed)
Abbreviation MS should not be used and _____ should be used instead.
Morphine sulfate
What types of patients are targeted for MTM?
Multiple conditions taking multiple medications Patients likely to incur annual costs for covered drugs that exceed a predetermined level
Healthcare providers should wear a mask or respirator, level ____ or higher when entering a airborne precaution room.
N95
______ are set annually by the TJC for different types of healthcare settings.
National patient safety goals (NPSGs)
What are communication related at risk-behaviors that can compromise patient safety?
Not addressing questions/concerns Rushed communication
In the even that a sharps container is not available patients can recap needles using which method?
One-hand method
______ are effective agents used for moderate to severe post-surgical pain and are the mainstay of treatment.
Opioids
What are technology related at risk-behaviors that can compromise patient safety?
Overriding computer alerts without proper consideration Not using available technology
Opioids may be administered through _____ devices allowing the patient to treat pain quickly and allows for the administration of small doses to reduce side-effects.
Patient controlled analgesia (PCAs)
Who within the hospital should be informed of the error?
Pharmacy and Therapeutics committee (P&T) Medication Safety Committee
What other means of instruction can be provided to patients to help educate if verbal communication is not enough?
Pictures Graphs Charts
What are the components of a MTM session?
Preparing a personal medication record (PMR) Developing a medication-related action plan (MAP) Interventions Referrals Documentation Plans for follow-up
Sharps should be disposed of in an FDA-cleared sharps container that has what qualities?
Puncture resistant Labeled or color coded Closable Leak-proof
What are common automated dispensing cabinets used?
Pyxis Omnicell ScriptPro Accudose
What are the core elements of the NPSG 07.03.01, 07.04.01, 07.05.01, 07.06.01: implement evidence-based practices to reduce healthcare associated infections?
Recommendations to prevent healthcare-associated infections with MDR organisms (MRSA, C.diff, VRE, MDR gram-negative bacteria) Comply with CDC hand hygiene guidelines
What are the core elements of the NPSG 02.03.01: Improve the effectiveness of communication among caregivers.?
Report critical issues of tests and diagnostic procedures on a timely basis (includes lab and blood culture results) Protocols must include acceptable length of time for reporting
What are the 5-rights when administering medications?
Right patient Right medication Right dose Right time Right route
______-dose vials are preferred over ______-dose especially when medications will be administered to multiple patients.
Single Multiple
_______ mixes upper and lower case letters to draw attention to dissimilarities in the drug name.
Tall man lettering
______ is an independent, not-for-profit, organization that accredits and certifies more than 17,000 healthcare organizations and programs in the US including hospitals, healthcare networks, long-term care facilities, home care organizations, office-based surgery centers and independent laboratories.
The Joint Commission
What are the organizations actively involved in improving medication safety?
The Joint Commission (TJC) Institute for Safe Medication Practices
T/F: Abbreviations are unsafe and contribute to many medical errors.
True
T/F: Adverse drug reactions are generally not avoidable, but can be more likely to occur if the drug is given to high-risk patients.
True
T/F: Alcohol-based hand rubs are considered more effect in the healthcare setting than plain soap or antimicrobial soap and water.
True
T/F: All KCl vials should not be on floor stock.
True
T/F: Barcoding improves automated dispensing cabinet use safety.
True
What are work environment related at risk-behaviors that can compromise patient safety?
Trying to do multiple things at once Inadequate supervision and orientation/training
What are common types of hospital-acquired (nosocomial) infections?
Urinary tract infections from indwelling catheters Blood stream infections from IV lines and catheters Surgical site infections Decubitus ulcers Hepatitis C. diff Pneumonia
What are the core elements of the NPSG 01.01.01: Improve the accuracy of patient identification?
Use at least 2 patient identifiers when providing care, treatment, and services Appropriate identifiers include name, medical record number, or date of birth Inappropriate identifiers include zip code, physician name, room number
What are the core elements of the NPSG 03.05.01: reduce the likelihood of harm associated with anticoagulant therapy?
Use standardize dosing protocols Use programmable pumps for heparin Provide education to patients and family Protocols should include starting dose ranges and alternate dosing strategies Communication with dietary to address drug-food interactions Baseline INR Frequency of INR monitoring Monitoring for bleeding and HIT
A PCA is administered with ______ for synergistic benefit in pain relief.
anesthesia
The most important and most cost-effective strategy to minimize catheter-related bloodstream infections is through _____ during catheter insertion.
aseptic technique (proper hand-washing)
The ______ is used at bedside to reduce medication errors by identifying that the correct drug is going to the right patient.
barcode
Antimicrobial hand soaps that contain ______ may be preferable to reduce infections in healthcare facilities.
chlorhexidine
A ______ refers to a patient requiring emergency medical care, typically for cardiac or respiratory arrest.
code blue
Errors of ______ means that something was done incorrectly.
commission
Errors may be discovered during a ______, through the process of medication therapy managment.
comprehensive medication review
Root cause analysis are often considered repetitive and is frequently viewed as an important _____ tool.
continuous quality improvement (CQI)
Abbreviation of QD and QOD should not be used, ______ and ______ should be used instead.
daily every other day
Needles used for withdrawing blood or any other bodily fluid should preferably have ______ which reduces the risk of an exposure incident.
engineered sharps protection
Due to the high-risk associated with heparin overdose, ______ vials should not be present in patient care areas.
high concentration heparin
Staff education programs such as ____ should be provided whenever new high alert medications are being used in the facility to introduce procedural changes aimed at preventing medication errors and to introduce any new guidelines.
in-services
Abbreviation of IU should not be used and ______ should be used instead.
international unit
Abbreviation of MSO4 and MgSO4 should not be used and ____ should be used instead.
magnesium sulfate
Measurements should be recorded in the _____ system only.
metric
Never reinsert used ______ into a multiple-dose vial or solution container.
needles
Errors of ______ means that something was left out that is needed for safety.
omission
All insulin infusions should be standardized to ______.
one concentration
A ______ is prepared and a __________ is developed during a MTM.
personal medication record (PMR) Medication-related action plan (MAP)
TJC requires that the _____ review the order before the medication can be removed from the automated dispensing cabinet for patient, except in special circumstances (an override).
pharmacist
An analysis can be done _____ to identify pathways that could lead to errors and to identify ways to reduce the error risk.
prospectively
A _____ is a retrospective investigation of an event that has already occurred which includes reviewing the sequence of events that lead to the error.
root cause analysis (RCA)
A ________ is an unexpected occurrence involving death or serious physical or psychological injury or risk thereof.
sentinel event
If a unit dose medication is not available for a crash cart, it is best to have prefilled _____ and _____ in the cart because it is easy to make mistake under the stress of a code.
syringes, drips
Drugs that are easily mixed up should be labeled with _______.
tall man letters
Never touch the ____ or _____ of a syringe.
tip plunger
Medication reconciliation should be done at every _____ in which new medications are ordered or existing orders are rewritten.
transition of care
Abbreviation of U, u should not be used and _____ should be used instead.
unit
The medications in a crash cart should be _____ and ______ including pediatric-specific doses.
unit dose Age-specific
The letters that are ______ case in tall man lettering are the ones that are different between the two look-alike, sound-alike drugs.
upper
All fluids containing potassium should be labeled with what?
"Potassium Added"