Define the subcategories of adverse events.
(There are 3…)
- Preventable adverse events
- Ameliorable adverse events
- Adverse events due to negligence
Preventable adverse events are due to error; ameliorable events could have been less harmful; negligence events fall below expected standards.
Compare and contrast errors of commission vs. errors of omission.
- Errors of commission: doing something wrong
- Errors of omission: failing to do the right thing
Both types expose patients to potentially hazardous situations.
Identify internal human factors that affect performance.
(There are 7 factors…)
- Limited memory capacity
- Fatigue
- Stress
- Hunger
- Illness
- Language limitations
- Hazardous attitudes
These factors can significantly impact how humans perform tasks.
Identify external human factors that affect performance.
(There are 7 factors)
- Noise
- Heat
- Light
- Long work schedules
- Inadequate training
- Poorly designed rules or procedures
- Interruptions and distractions
External factors can create an environment that leads to errors.
Explain the Swiss Cheese model of error.
Active errors are signs of latent errors that may allow hazards to slip through gaps
The model illustrates how system failures can lead to serious patient harm through a series of breakdowns.
Define medication error.
Any preventable event that may cause or lead to inappropriate medication use or patient harm
Medication errors account for approximately one-third of all medical errors.
Define Culture of Safety.
A workplace culture where error reporting is encouraged and used to improve processes
It focuses on process flaws rather than targeting individuals.
What are the Five Rights of Medication Administration?
(There are 5…)
- The right patient
- The right drug
- The right dose
- The right route
- The right time
These rights help ensure safe medication practices.
True or false: Near miss refers to an unsafe situation that results in patient harm.
FALSE
A near miss is an unsafe situation that does not result in harm, either through luck or early detection.
What is the estimated annual cost of medication error morbidity and mortality?
$77 billion dollars per year
This figure does not include lost wages and productivity or additional healthcare costs.
What is the role of the pharmacist in medication safety?
(There are 4…)
- Make medication safety a priority
- Improve reporting behavior of medication errors
- Participate in inter-professional teams
- Document financial burden of medication errors
Pharmacists play a crucial role in enhancing the medication use process.
Define adverse drug event.
Any injury caused by a medication
This term encompasses a range of negative outcomes related to medication use.
What is the purpose of root cause analysis?
To identify what, how, and why something happened, preventing recurrence
It involves data collection, root cause identification, and recommendation generation.
Fill in the blank: Adverse drug reactions are unexpected, unintended, undesired, or excessive response to a _______.
medicine
These reactions can significantly impact patient safety.
What does the Institute of Medicine report state about errors?
Errors are inherent to human nature
The report highlights the prevalence of medical errors and their impact on patient safety.
What is a medication misadventure?
Any hazard or event associated with medications
It may or may not cause injury to a patient.
What is the importance of involving the patient in medication safety?
Patients can help identify errors with medication or treatment
They serve as the last point of verification prior to medication administration.
