Term
| Why is patient safety so hard? (4 challenges) |
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Definition
Visibility, Ambiguity, Complexity, and Autonomy
Visibility: low visibility = no urgency. if you dont tell someone about an error after you fixed it, someone else can walk in and make the same error.
Ambiguity: combination of issues, difficult to pinpoint the cause.
Complexity: paralysis by analysis. don't even know where to start!
Autonomy: Desire to take care of my pt my way. Reluctance to correct a peer |
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Term
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Definition
| errors that occur at the sharp end of the process |
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Term
| ____ Errors occur at the sharp end of the process. |
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Definition
| Active errors (ex.Saying one word when you intended to say another, taking the wrong turn to go to work on your day off, when you intended to go elsewhere) |
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Term
| ______ errors occur at the blunt end. These are decisions made away from the bedside that impact the care. |
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Definition
| Latent errors. (ex. Place two LASA drugs next to each other, or equipment flaws, organization flaws like short-staffing, A corporation delegating to a temporary agency the responsibility for doing criminal checks on new hires, without verifying that these are being done.) |
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Term
| Active or latent error? --> Unclear handwriting on a new patient prescription |
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Definition
| Latent to pharmacist. Active to MD |
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Term
| Active or latent error? --> Taking the wrong turn to go to work on your day off, when you intended to go elsewhere |
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Definition
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Term
| Active or latent error? --> A software bug that turns off your computer in mid-task. |
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Definition
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Term
| What does this describe? --> discipline for purposeful action, changes for system design issues |
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Definition
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Term
| Who is W. Edwards Deming? |
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Definition
| One of the gurus for systems thinking. He is a systems engineer |
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Term
| What are common cultural drivers? (4 of them) |
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Definition
| Time pressure, Cost-cutting, Indifference to hazards, Pursuit of commercial advantage |
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Term
| _________ is an injury caused by medical treatment, not necessarily due to an error |
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Definition
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Term
______ is an injury, large or small, caused by the use of a drug.
-Preventable
-Non-preventable |
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Definition
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Term
_____ 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.
or
Preventable events that occur at any stage in the medication use process resulting in patient harm (Adverse Drug Event) or inappropriate medication use.
-prescribing
-dispensing
-administration |
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Definition
Medication Error
Not counseling a pt can be called an error, or not looking at the lab values, or not asking a pt certain questions |
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Term
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Definition
NCC-MERP is a system developed to categorize medication errors which you will see in many hospitals.
See pie chart with categories A - I.
Category A is Circumstance/event that has capacity to cause error
Category B-D: Error occurred but patient not harmed.
Category E-H: Error occurred and resulted in harm
Category I: Error occurred and patient DIED |
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Term
What is the most common type of Medication Error?
a) Prescribing
b) Dispensing
c) Administering
d) Monitoring |
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Definition
a) Prescribing
Second is Administering |
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Term
What is the most common type of Prescribing Error?
a) Wrong form
b) Allergy
c) Wrong dose
d) Wrong drug |
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Definition
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Term
What is the most common Dispensing Error?
a) Wrong drug
b) Wrong time
c) Wrong dose
d) Missed dose |
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Definition
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Term
| What type of pharmacy malpractice insurance claim is the most commonly seen according to Pharmacists Mutual Claims company? (between 1989-2006) |
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Definition
| Wrong drug @ 50.3%. Second was wrong strength @ 28% |
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Term
According to a survey chart from Drug Topics in 2009, what was the most common cause of error?
a) Entry- Entered incorrect directions
b) Entry- Selected incorrect patient profile
c) Entry- Incorrect refill info |
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Definition
c) Entry- incorrect refill info
Second is a) Entry- Entered incorrect directions |
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Term
These are examples of _______ Errors:
Missed
Wrong order
Wrong time
Not sent to pharmacy
No allergy info
a) Prescribing errors
b) Transcribing errors
c) Dispensing errors
d) Administration errors |
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Definition
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Term
These are examples of ______ Errors:
Indication
Contraindication
Allergy
Dose
Illegible/unapproved abbreviations
Incomplete
Change/previous order still active
a) Prescribing errors
b) Transcribing errors
c) Dispensing errors
d) Administration errors |
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Definition
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Term
These are examples of ________ Errors:
Computer entry
Misfill
Check
Delivery
Drug interaction
a) Prescribing errors
b) Transcribing errors
c) Dispensing errors
d) Administration errors |
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Definition
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Term
These are examples of _____ Errors:
Inpatient
-Missed dose (not giving the med)
-Missed documentation (not writting that u gave dose )
-Wrong patient
-Wrong time
-Wrong dose
-Wrong route/form
Outpatient
-Insurance (Someone's insurance changes so pt does not take anything)
-Directions (Not giving meds right)
-Drug/herbal interactions
a) Prescribing errors
b) Transcribing errors
c) Dispensing errors
d) Administration errors |
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Definition
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Term
Is this Error of Commission or Omission?
Give patient the correct drug but it is under-dosage |
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Definition
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Term
| There were many reports (2004-2006) of children under 6yo getting a wrong dose, with dosing errors off by a factor of __ fold |
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Definition
| 10 fold error rate. probably because of parents using silverware to measure doses. |
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Term
| Acetaminophen is the most common cause of acute liver failure in the US. T/F? |
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Definition
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Term
| What does the International Standard (1994) state..? |
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Definition
| It says that 1500 pts must be exposed to a drug, at least 600 pts have to take the drug for 6 month and 300 pts must take that drug for 1 year…and we can detect ADR in 1 out of 300-500 pts, so lots of ppl have to get the drug to predict these things. Once released to millions of people, ADRs will start showing up. |
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Term
| What are the 8 problems with current FDA approval process? |
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Definition
1. Uncommon, serious ADRs are not detected in preapproval studies
2. Massive underreporting of ADRs in postmarketing surveillance
3. Manufacturers do not fulfill postmarketing surveillance safety study commitments
4. FDA lacks authority to pursue sponsors who violate regulations
5. Public perception of FDA as too close to Pharmaceutical manufacturing industry
6. Safety oversight structure at FDA is faulty
7. Shortage of drug safety & public health experts in FDA & committees
8. System is inappropriately funded & relies on industry fees to function |
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Term
| What are the Proposals for improvement in Drug Safety? |
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Definition
1. Give FDA more direct legal authority
2. Adopt a conditional approval policy
3. Provide resources for safety infrastructure at FDA
4. Reorganize FDA with emphasis on proactive monitoring of drug safety
5. Broader representation of drug safety & epidemiology experts on advisory committees |
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Term
| Lucian Leape- 3 biggest sources of drug related problems can be solved by: |
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Definition
-Drug Knowledge Dissemination
-Checking Dose/Identity of Drug
-Patient Information |
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Term
| _____ Case is when discounted financial benefits exceed discounted financial costs whether they accrue to patients, payers, employers, the health care system, or society |
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Definition
Economic Case
for a health care intervention |
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Term
| ______ Case is when an intervention benefits society regardless of cost. |
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Definition
Social Case
for a health care intervention: |
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Term
| ______ Case is when the investing entity realizes a real or estimated financial return within a reasonable time frame. |
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Definition
Business Case
for a health care intervention |
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Term
| What is: Profits or losses suffered in an expenditure of money, time or effort |
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Definition
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Term
| What are the two primary factors that influence the need for a business case? |
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Definition
1. Organization’s mission
What is more important - cost or benefits
2. Time period being discussed
Is the organization willing to wait for long term benefits or do they need short term satisfaction |
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Term
Which of the following need to see profits?
a) Business Case
b) Economic Case
c) Social Case |
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Definition
| only Business Cases. Economic and Social do not rely solely on profits as determining factor. |
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Term
Total financial (e.g., cost in dollars) or non-financial inputs (e.g., aggravation) spent on a quality intervention
a) Costs
b) Benefits
c) Benefits-to-Cost Ratio
d) Return on investment
e) Breakeven Point |
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Definition
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Term
Total financial (e.g., revenue in dollars) or non-financial outputs (e.g., personal satisfaction) received for providing the quality
a) Costs
b) Benefits
c) Benefits-to-Cost Ratio
d) Return on investment
e) Breakeven Point |
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Definition
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Term
Ratio of benefits to costs from an intervention. An amount equal to one “breaks even” and an amount greater than one is a positive return-on-investment.
a) Costs
b) Benefits
c) Benefits-to-Cost Ratio
d) Return on investment
e) Breakeven Point |
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Definition
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Term
Point where benefits exceed costs
a) Costs
b) Benefits
c) Benefits-to-Cost Ratio
d) Return on investment
e) Breakeven Point |
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Definition
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Term
[(Benefits-Costs)/(Costs)] * 100
a) Costs
b) Benefits
c) Benefits-to-Cost Ratio
d) Return on investment
e) Breakeven Point |
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Definition
Return on Investment
ROI of 1 or above is good |
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Term
Describe the Service-Profit Cycle ( Using QI to generate revenues)
...whereas the Deming’s Quality Chain Reaction diagram ( Using quality improvement to lower costs)
Combining the two above is shown in the Return on Quality diagram (Using QI to lower costs AND generate revenues) |
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Definition
| Service-Profit Cycle is to increase revenues…small things make ppl happy. Internal marketing (make good work environment) leads to employment satisfaction and it will equal to retention of employees and happy employees then they will give better quality service, which will have happy satisfied customers and we will have more loyal customers...FIRM PROFITABILITY |
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Term
| What are three Problems Seen in Building a Business Case? |
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Definition
1. poorly designed or implemented quality initiatives
2. building an economic case but not a business case
3. ignoring nonfinancial benefits of quality improvement |
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Term
Which of the following are ways to alleviate Prescribing Errors:
a) Increase training
-Importance of standardizing
=Policy & protocols
=Computerized order entry
-Selection, dosing and factors that
affect dosing
-Decrease abbreviations
b)Increase information
c)Formal, group feedback
d)Standardization
e)a, b, and c only
f)all of the above |
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Definition
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Term
Which of the following are ways to alleviate Administration Errors:
a) Standardization
-Independent double checks
-Dose and infusion rate charts
-Discharge counseling by pharmacists
b)Increase information
c)Automate carefully
-Computerized infusion devices
-Magnifiers
d)all of the above
e)two of the above |
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Definition
| e) two of the above (i.e. standardization and automate carefully) |
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Term
| True of False? --> Not all states require 'Mandatory Notification of Adverse Events to Patients' if one has occurred….Florida does require it and we have to fill out a sheet. |
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Definition
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