Prevent & Manage Med Errors

Question 1

Describe systems thinking perspective.

Answer 1

• discipline for seeing wholes
• framework for seeing interrelationships, patterns of change
• sensibility – for the subtle interconnectedness that gives living systems their unique character

Question 2

Front end errors

Answer 2

• Focus on front-line practitioner
• Assign blame
• Punitive action
• Prevention by changing people and their behaviors

Question 3

Latent errors

Answer 3

- Focus on weaknesses in
organizational structure
- Prevention by improving the system
- For example: 
• Ineffective personnel training 
•  Incomplete patient information 
•  Unclear communication of a drug order 
•  Lack of independent double-check before dispensing

Question 4

What are system-based causes of medication errors? (not an objective)

Answer 4

• Patient information
• Drug information
• Communication of drug information
• Drug storage, stock, and distribution
• Environmental factors
• Staff competency and education
• Patient education
• Quality processes and risk management

Question 5

Identify common causes of errors associated with ordering medications

Answer 5

• Illegible handwriting
• Look-alike, sound-alike drug names
• Abbreviations
• Ambiguous orders
• e-Prescribing

Question 6

Strategies to minimize errors with illegible handwriting

Answer 6

• Block letters
• Indication
• Computerized physician order entry
• Pre-printed orders
• Multi-stage checks

Question 7

Strategies to minimize errors with look-alike drug names

Answer 7

• Read back
• Spell drug name
• Tall man lettering

Question 8

Strategies to minimize errors with abbreviations

Answer 8

Avoid the following:

• U for “units” D/C
• Q for “every” (QD, QID, QOD, qd, qid, qod)
• MgSO4 (Mg) and MSO4 (MS)
• MTX
• AZT
• HCT and HCTZ

Question 9

Strategies to minimize errors with ambiguous orders

Answer 9

• be careful with zeroes and decimal points
• specify strengths
• use fractions and not slashes because it can be mistaken for a 1
• use both mg and mL for liquids
• order with proper unit expression
• have proper spacing

Question 10

How does e-prescribing errors happen?

Answer 10

• Memorize parts of e-prescriptions
• Perform dosage calculations mentally
• Communication issues with prescribers and patients

Question 11

What are things that could go wrong with e-prescriptions?

Answer 11

Wrong:

• drug quantity
• dosing directions
• duration of therapy
• dosage formulation
• drug class

Question 12

Identify common causes of errors associated pharmacist handoffs.

Answer 12

• Overload
• Underload
• Scatter
• Conflict
• Erroneous

Question 13

Identify strategies to reduce errors associated with preparing / dispensing medications

Answer 13

• Read label three times: when product is selected, when it is prepared, when it is returned back on the shelf or disposed of
• Separate drugs with similar-sounding names
• Change appearances of certain drug names

Question 14

With patient education and counseling, what are outcome of error-prevention efforts influenced by?

Answer 14

• Direct patient education
• Health literacy
• Patient compliance

Question 15

Identify strategies to reduce errors associated with counseling / educating patients.

Answer 15

• State laws for mandatory counseling

- Private area for Rx pick-up

Question 16

Explain the important of health literacy (not an objective)

Answer 16

• Approximately one-third of U.S. adults have limited health literacy
• Have difficulty reading and understanding medication instructions and information
• Hesitant to ask questions

Question 17

Identify some medication error reduction strategies

Answer 17

• Fail-safes & constraints (system change; no KCl on floor)
• Forcing functions (hard stop; wt before heparin; bar codes)
• Automation and computerization (e-prescribing)
• Standardization (pre-printed Rx pads, standard order forms)
• Redundancies (duplicate steps, patient counseling)
• Reminders & checklists (auxiliary labels, LASA med alerts)
• Rules and policies
• Education and information
• Suggestions to be more careful or vigilant