Professional Documents
Culture Documents
Safety
Chapter 6
Group 3
12 Cu, Emmanuel Romeo K.
13 David, Patrick P.
14 de Leon, Jeremia Ydianne
15 de Leon, Princess Marielle R.
16 Del Rosario, Krizia Ashter V.
17 Delmendo, Christine A.
INTRODUCTION
Medication safety are ways in the
prevention of fatalities and detection of
harm when administering medicinal doses.
Know which medications are high risk so
we can take precautions.
STEPS IN MEDICATION
1. PRESCRIBING
2. ADMINISTERING
3. MONITORING
PRESCRIBING
Choosing an appropriate medication for a given
health problem of the patient
Deciding the time, dose and route in
administration of the medication.
ADMINISTERING
obtaining the medication then preparing it by
mixing, labeling or counting
giving the medication to the correct patient with
the prescription having the right instructions for
the time, route and dose
MONITORING
observing the patient to check if the medication
works, any adverse effects occur, or if the patient
uses the drug the right way.
Allergic Reactions
An allergic drug reaction is a type of ADR resulting
from immunologic hypersensitive to drug
Dispensing error
Drug Misadventure
Drug-related morbidity
The failure of a drug to achieve its intended health
outcome due to unresolved drug-related problems. It
is a negative outcome associated with an error
Drug-related problems
Error of Commission
An error that results when the patient receives the
correct drug in a way that does not result in optimal
patient outcomes or an incorrect drug which puts the
patient at risk of negative outcomes
Error of Omission
An error that results in a patient failing to receive a
beneficial drug
Idiosyncratic Reaction
A type of ADR resulting from abnormal responses to
drugs that are peculiar to individuals
Latent Injury
A propensity or predisposition for harm during the
process of care that actually does not result in
patient injury
Medication error
Any error in the medication process (prescribing,
dispensing, administration of drugs), whether there
are adverse consequences or not
Medication Reconciliation
The process of resolving discrepancies as patients
transition across departments (e.g., a medical ICU to
a step down unit), locations (e.g., inpatient to
outpatient), or other places
Monitoring Error
The failure to review a prescribed regimen for
appropriateness and detection of problems, or failure
to use appropriate clinical or laboratory data for
adequate assessment of patient response to
prescribed therapy
Outcome
The end result attributable to health care products or
services such as mortality, infection, myocardial
infarction, and plain.
Prescribing Error
An incorrect drug, dose, dosage form, quantity, route,
concentration, rate of administration, or instructions
for use that has been ordered or authorized by a
prescribe. It includes illegible prescriptions or
medications orders that has lead to errors that reach
the patient
Process
These are actions associated with quality such as
reviewing patient orders prior to dispensing,
conducting drug use evaluation, and counseling
patient prior to discharge.
Sentinel Event
An unexpected occurrence involving actual or
potential death or serious injury. These events signal
the need for immediate investigation and response.
Side effect
An expected, well-known reaction resulting in little
or no change in patient management (e.g., drowsiness
or dry mouth associated with certain antihistamines)
Structure
The presence of something that is reasonably
associated with quality such as pharmacy, a
pharmacist available references, 24-hour pharmacy
service, a formulary, and a computerized prescriber
order entry system.
Transcription and/or
Interpretation Error
Trigger Event
An event occurring during the patient treatment that
causes a latent injury that may become an actual
discernible injury
DEFINITIONS
o DRUG-RELATED PROBLEMS
DRPs are events associated with drug therapies
that can or do hamper optimal patient health
outcomes.
DRPs include medication errors, adverse drug
reactions, adverse drug events, and side effects.
o MEDICATION MISADVENTURES
A term very similar to DRPs commonly used in
institutional safety studies.
Medication misadventures are iatrogenic hazards
or incidents associated with indicated drug
therapy resulting in patient harm that can be
attributable to error, immunologic response, or
idiosyncratic response.
o MEDICATION ERRORS
Are errors or mistakes in the medication use process
(prescribing, dispensing, administering of drugs) that
may result in negative outcomes.
Not all DRPs are medication errors because problems
in medication use can occur even when best
medication practices are applied.
o MEDICATION ERRORS
>By their impacts on patients
>Where they exist in the medication use system
o ADMINISTRATION ERRORS
These occur when patients are administered
something other than that prescribed for the
patient
o wrong dose,
o omitted dose,
o additional dose,
o wrong administration time,
o incorrect handling of drugs during
administration, or
o wrong infusion rate
o DISPENSING ERRORS
Are mistakes made during the dispensing process
where
a patient receives the wrong drug,
o the correct drug received by a wrong
patient,
o Wrong galenic form,
o Wrong dose
o PRESCRIBING ERRORS
Occurs when prescriptions have incorrect drug
selection, dose, dosage form, quantity, rate of
administration, or instructions for use of a drug
product.
These include illegible prescriptions or medication
orders that lead to errors that reach the patient.
o MONITORING ERRORS
Results from failure to review a prescribed
regimen for appropriateness or the failure to use
appropriate clinical or laboratory data for
adequate assessment of patient response to
prescribed therapy.
o SIDE EFFECTS
Are not ADRs.
They are expected, well-known reactions that
require little or no change in patient
management.
>They may or may not be results of medication
errors.
>Allergic reactions and Idiosyncratic reactions are
considered ADRs.
Preventing Medication
Errors
Medication errors occur because of:
Poorly designed medication
labels
Poor personnel
management practices
o Inadequate performance
feedback
Lack of quality
improvement system
Equipment failures
Look-alike or sound-alike
drugs
Sloppy communication
o Illegible handwriting
o Incorrect transcription
o Verbal miscommunications
Institute of Medicine
Recommendations:
Institute of Medicine
Recommendations for the pharmacists:
Must keep up with medication literature for drug error
information and take action for prevention
Patient identities must be verified with bar codes
Patients should be educated about ways to prevent medication
errors
Patients should be engaged in managing their own medication
regimens.
Electronic prescribing should be used.
Trivial warnings should be avoided in medication-support
systems.
Prescription filling technology needs to be assessed and improved
Pharmacist should monitor patients with high risk side effects
Pharmacists should routinely review medication records
especially when transitioning between types of care
Culture of Safety
Exists where safety is the key element of
everyones job ( leadership-technicians and unit
secretaries)
Leaders encourage workers to seek out and
implement new ways of ensuring the safety of
patients
Action and words
Take responsibility for protecting the well-being of
patients
Pressure to solve medication problems comes from
technicians, pharmacists and supervisors
Information is shared
(reducing patient risk > disclosure)
Culture of Safety
Culture of blame
o Reporting of medication errors is discouraged by
attempts to find someone to blame and punish
o Risk of reprisal discourages anyone to report them
Plan
In this step, we clarify the purpose of the
quality improvement effort by having a bottomup approach including everyone, especially the
frontline healthcare workers.
We develop here the description or the cause of
the problem before formulating an action plan,
and if possible, a back-up plan.
Do
Plans are enforced into actions during this stage.
They maybe done in a small scale form so as to
let them eventually adjust to their plan.
Data as well as unexpected problems or
outcomes must be documented for further
studying on the next stage.
Study
We evaluate the product of stage two here.
Re-evaluation occurs here to see if the
outcome meets the expectations of the plan.
If they see the change as a good effect towards
the betterment of the patients, they may allow
it to be added to the system.
Act
The change that was planned is now in action
here. They re-assess and monitor it again to se
if it acts as efficiently as they thought.
If that change does not meet with what the
team wants, the will formulate once again a
plan and develop the desired outcome.
PROCESS
OUTCOME
STRUCTURES
These are measures of the presence of
something that is reasonably associated
with quality
These are desirable for assessing the
quality of health care because they are
easy to measure
The problem is that their relationship with
quality and patient safety is not always
clear or established.
1) Formulary system
2) Effective human resources management
3) Adequate staffing
4) Suitable work environments
5) Lines of authority and areas of responsibility
6) Systematic program of quality improvement and peer review
7) Clinical information about patients
8) Patient medication profiles
9) Pharmacy department responsibilities
10)Computerized pharmacy systems
11)Unit dose systems
12)Pharmacists access to electronic health records
13)Computerized Prescriber Order Entry
14)Medication references
15)Standard drug administration times
16)Standard abbreviations
17)Review mechanism
18)Educational programs
PROCESSES
These are actions reasonably associated with
quality such as the checking of patient
medication profiles prior to dispensing, double
checking technician work, and electronic
prescribing.
Better than measuring presence of structures
It is still possible that widely accepted
practices are not always associated with
positive patient health consequences.
OUTCOMES
The quality of safety systems needs to be
assessed by their impact on patient
health outcomes dissatisfaction,
discomfort, disability, disease, and death.
Achieving positive health outcomes is
the real purpose of having quality
structures and processes.
Hardest to link to safety efforts
I. Concurrent Surveillance
System
During drug therapy
A. Forms:
1. Based on reports of suspected ADRs by
pharmacists, nurses, physicians, or
patients.
2. Alerting orders
Alerting Orders
Prescriptions which alert pharmacists that
an ADR may have occurred and that an
investigation needs to be conducted.
A. Types:
1. Tracer Drugs
2. Abrupt discontinuation or decrease in
dosage
3. Stat orders for laboratory assessments of
therapeutic drug levels
Tracer Drugs
Commonly used to treat ADRs
Ex. Orders for immediate doses of
antihistamines, epinephrine, and
corticosteroids
Abrupt discontinuation or
decrease in dosage of a drug
Because of a negative reaction to the medication
Insulin
Methotrexate for nononcologic use
Sedatives midazolam
Narcotics/opiates
Neuromuscular blocking
agents succinylcholine
Nitroprusside
Oxytocin(IV)
Potassium chloride and
sodium chloride for injection
Promethazine(IV)
Radiocontrast agents
Total parenteral nutrition
2. Elderly
- Polypharmacy, multiple prescribers, adherence
problems, changes in renal function, metabolism,
sensitivity
3. Oncology patients
- Exposure to highly toxic regimens
- Immunocompromised
Medication reconciliation
Is the process of resolving discrepancies with
what the patient has been taking in the past
with what the patient should be taking at the
moment.
Is meant to be conducted each time a patient
transitions across departments, locations, or
other location.
Step 3: Reconciliation
- Clinical decisions are then made based upon a
comparison of newly prescribed medications against
what was prescribed previously. Changes to
pharmacotherapy are documented in all relevant
records.
Step 4: Transmission
- Therapy changes are communicated to those people
who need to know about the changes including
providers on both end of transition (e.g., hospital
pharmacist and community pharmacist, surgeon,
internist, caregivers, and the patient.) This includes
providing the patient or caregiver with a copy of final
medication list with administration instructions.
Joint Commission
- an independent, not-for-profit organization dedicated to
improving the safety and quality of health care
- assesses and accredits the quality of health systems.
- is the principle accrediting body for the operation of
hospitals and other health care organizations.
References
Minnesota Department of Health, (n.d.). PDSA: Plan-Do-StudyAct. Retrieved February 28, 2016 from
www.health.state.mn.us/divs/opi/qi/toolbox/pdsa.html