Medication Safety Quiz: Test Your Knowledge on Medical Errors

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is a method to reduce medication errors mentioned in the text?

Use of the Metric System (correct)

Use of Household System

Use of Customary System

Use of Imperial System

What is a practice for safe handling of emergency medications mentioned in the text?

Keeping Emergency Medications in Unmarked Containers

Dedicate Pharmacists To High Risk Areas (correct)

Not Having a Designated Emergency Medication Area

Assigning Emergency Medications to Any Available Staff

What is recommended to avoid in identifying medications based on, according to the text?

Color Alone

Shape Alone

Label Alone

Packaging Alone (correct)

What technology is mentioned for reducing medication errors in the text?

Barcoding Signup and view all the answers

What is the definition of medication errors?

Events that cause inappropriate medication use or patient harm Signup and view all the answers

Who is involved in improving medication safety?

The Joint Commission and the Institute for Safe Medication Practices Signup and view all the answers

What are sentinel events?

Unexpected occurrences involving death or serious injury Signup and view all the answers

What is believed to be the most common cause of medication errors?

System-based causes Signup and view all the answers

What do errors of omission involve?

Leaving out necessary information Signup and view all the answers

What should be reported to prevent similar errors in the future?

Medication errors, adverse drug reactions, hazardous conditions, and near misses Signup and view all the answers

What should institutions have in place for responding to medication errors?

A plan including internal and external notification, disclosure, investigation, and improvement Signup and view all the answers

How are adverse drug reactions different from medication errors?

Adverse drug reactions occur as side effects from medication use Signup and view all the answers

What do many state boards of pharmacy require to prevent medication errors?

Quality assurance programs Signup and view all the answers

What is the nature of medication error reporting systems within hospitals?

Many are electronic Signup and view all the answers

Who should hospitals inform of any errors?

Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee Signup and view all the answers

What is the purpose of using tall man letters in drug names?

To highlight dissimilarities in look-alike, sound-alike drug names Signup and view all the answers

Why are abbreviations considered unsafe in the medical field?

They contribute to many medical errors Signup and view all the answers

What is the purpose of the TJC's 'Do Not Use' abbreviation list?

To prohibit the use of unsafe abbreviations Signup and view all the answers

What is the recommended alternative for the abbreviation 'U' (unit)?

Zero Signup and view all the answers

Why are high-alert drugs designated as such?

They have a heightened risk of causing significant patient harm if used in error Signup and view all the answers

What is the purpose of using tall man lettering for high-alert drugs?

To highlight dissimilarities in look-alike, sound-alike drug names Signup and view all the answers

What is the purpose of drug dictionaries within computer systems and automated dispensing cabinets?

To prompt the provider to confirm the correct medication being ordered or withdrawn Signup and view all the answers

What is the issue with the abbreviation 'MS'?

It can mean morphine sulfate or magnesium sulfate Signup and view all the answers

Why are trailing zero (X.O mg) and lack of leading zero (X mg) problematic?

They can result in dosing errors Signup and view all the answers

What is the recommended alternative for the abbreviation 'IU' (International Unit)?

Write 'International Unit' Signup and view all the answers

Why is electronic prescribing preferred over handwritten prescriptions?

It can virtually eliminate errors associated with poor handwriting Signup and view all the answers

What is the purpose of limiting concentrations available in high-alert medications?

To prevent dosing errors and improve patient safety Signup and view all the answers

What is the purpose of the ISMP National Medication Errors Reporting Program (MERP)?

To provide confidential reporting of medication errors Signup and view all the answers

What is the purpose of Root Cause Analysis (RCA)?

To investigate events and design changes to prevent future errors Signup and view all the answers

What does Failure Mode and Effects Analysis (FMEA) aim to do?

Reduce the frequency and consequences of errors Signup and view all the answers

What is the role of The Joint Commission on Accreditation of Healthcare Organizations (TJC)?

Accredits and certifies healthcare organizations and programs Signup and view all the answers

What are National Patient Safety Goals (NPSGs) focused on?

Reducing harm associated with anticoagulant therapy Signup and view all the answers

What is the frequency of on-site surveys conducted by TJC for accredited organizations?

At least every three years Signup and view all the answers

What is the purpose of ISMP National Medication Errors Reporting Program (MERP)?

To provide confidential reporting of medication errors Signup and view all the answers

What is the focus of NPSGs regarding patient care, treatment, and services?

Using at least two patient identifiers Signup and view all the answers

What are professionals and consumers encouraged to do regarding medication errors?

Report medication errors on the ISMP website Signup and view all the answers

What is the role of the manufacturer when there are many reports of a particular error?

Take measures to increase safety Signup and view all the answers

What is the focus of NPSGs regarding diagnostic procedures?

Reporting critical results on a timely basis Signup and view all the answers

What is the purpose of Failure Mode and Effects Analysis (FMEA)?

To reduce the frequency and consequences of errors Signup and view all the answers

Is the use of 'Do Not Use' abbreviations recommended to reduce medication errors?

True Signup and view all the answers

Is medication reconciliation mentioned as a method to reduce medication errors?

True Signup and view all the answers

Is the use of the metric system recommended to identify medications based on packaging alone?

False Signup and view all the answers

Is hand hygiene mentioned as a method to prevent transmission of infections in hospitals?

True Signup and view all the answers

Is the use of tall man letters recommended to reduce confusion between similar drug names?

True Signup and view all the answers

Is the use of abbreviations considered safe in the medical field?

False Signup and view all the answers

Is electronic prescribing mentioned as a method to reduce errors associated with poor handwriting?

True Signup and view all the answers

Is handwritten prescriptions and progress notes no longer used in many settings?

False Signup and view all the answers

Are high-alert drugs with a heightened risk of causing significant patient harm designated as such?

True Signup and view all the answers

Are look-alike, sound-alike medications a common cause of medication errors?

True Signup and view all the answers

Are poor handwriting and similar product labeling mentioned to aggravate the problem of medication errors?

True Signup and view all the answers

Is the lack of leading zero (X mg) considered problematic?

True Signup and view all the answers

Are high-alert medications recommended to be used safely by developing protocols or order sets for use?

True Signup and view all the answers

Are trailing zero (X.O mg) and lack of leading zero (X mg) considered problematic?

True Signup and view all the answers

Is the purpose of using tall man letters for high-alert drugs mentioned in the text?

False Signup and view all the answers

Is the purpose of using tall man letters in drug names mentioned to reduce confusion between similar drug names?

True Signup and view all the answers

Root Cause Analysis (RCA) is a proactive investigation of an event that has occurred, used to design changes to prevent future errors.

False Signup and view all the answers

Failure Mode and Effects Analysis (FMEA) is a retrospective method used to reduce the frequency and consequences of errors.

False Signup and view all the answers

The Joint Commission on Accreditation of Healthcare Organizations (TJC) accredits and certifies over 20,000 healthcare organizations and programs in the U.S.

False Signup and view all the answers

NPSGs include goals related to reporting critical results of tests and diagnostic procedures on a timely basis, and labeling all medications and containers.

True Signup and view all the answers

NPSGs focus on reducing the likelihood of harm associated with anticoagulant therapy and maintaining accurate patient medication information.

True Signup and view all the answers

TJC conducts on-site surveys at least every four years for accredited organizations, with the possibility of unannounced surveys.

False Signup and view all the answers

ISMP National Medication Errors Reporting Program (MERP) is an anonymous national voluntary reporting program for medication errors.

False Signup and view all the answers

Professionals and consumers are discouraged from reporting medication errors on the ISMP website if the error was reported internally.

False Signup and view all the answers

When there are many reports of a particular error, the manufacturer may not be required to take measures to increase safety.

False Signup and view all the answers

FMEA is a proactive method used to increase the frequency and consequences of errors.

False Signup and view all the answers

RCA is a retrospective investigation of an event that has occurred, used to design changes to prevent future errors.

True Signup and view all the answers

MERP is a confidential national voluntary reporting program for medication errors.

True Signup and view all the answers

Sentinel events require investigation and measures to prevent recurrence.

True Signup and view all the answers

Errors of omission involve leaving out necessary information, while errors of commission involve doing something correctly.

False Signup and view all the answers

Adverse drug reactions (ADRs) are the same as medication errors.

False Signup and view all the answers

Many state boards of pharmacy require quality assurance programs to prevent medication errors and mandate reporting errors to patients and prescribers.

True Signup and view all the answers

Error investigations need to take place quickly, and many medication error reporting systems within hospitals are paper-based.

False Signup and view all the answers

Hospitals should inform their Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee of any errors.

True Signup and view all the answers

The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) are not actively involved in improving medication safety.

False Signup and view all the answers

Experts believe that individual errors are the most common cause of medication errors.

False Signup and view all the answers

Medication errors, adverse drug reactions, hazardous conditions, and near misses should not be reported to prevent similar errors in the future.

False Signup and view all the answers

The purpose of using tall man letters in drug names is to confuse similar drug names.

False Signup and view all the answers

The Institute of Medicine (IOM) found that up to 98,000 Americans die each year in U.S. hospitals due to preventable medical errors, 7,000 from medication errors alone.

True Signup and view all the answers

Institutions should not have a plan in place for responding to medication errors, including internal and external notification, disclosure, investigation, and improvement.

False Signup and view all the answers

Match the following methods to reduce medication errors with their descriptions:

Tall Man Lettering = To differentiate look-alike drug names Medication Reconciliation = To ensure accurate and complete medication information transfer Computerized Prescriber Order Entry and Clinical Decision Support = To prevent errors in prescribing and provide decision support for clinicians Barcoding = To verify medication administration and reduce errors in dispensing Signup and view all the answers

Match the following infection control measures with their purposes:

Universal Precautions = To prevent transmission of infections in healthcare settings Catheter-Related Bloodstream Infections = To reduce infections related to catheter use Hand Hygiene = To prevent transmission of pathogens through hand contact Patient Controlled Analgesia Devices = To minimize infection risk associated with pain management devices Signup and view all the answers

Match the following safe practices for emergency medications with their purposes:

Dedicate Pharmacists To High Risk Areas = To provide specialized oversight in high-risk medication areas Monitor for Drug-Food Interactions = To prevent adverse reactions from combining medications with food Safe Practices For Emergency Medications / Crash Carts = To ensure rapid access to essential medications during emergencies Education = To inform healthcare professionals and patients about medication safety Signup and view all the answers

Match the following technology and automated systems with their roles in medication safety:

Automated Dispensing Cabinets = To securely store and dispense medications in healthcare facilities Computerized Prescriber Order Entry and Clinical Decision Support = To electronically enter and manage medication orders with decision support Barcoding = To verify patient and medication identification during administration Patient Controlled Analgesia Devices = To automate and control the administration of pain medications Signup and view all the answers

Up to 98,000 Americans die each year in U.S. hospitals due to preventable medical errors, 7,000 from medication errors alone.

True Signup and view all the answers

The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) are not actively involved in improving medication safety.

False Signup and view all the answers

Sentinel events involve expected occurrences that do not require investigation.

False Signup and view all the answers

System-based causes, rather than individual errors, are the most common cause of medication errors.

True Signup and view all the answers

Errors of omission involve doing something incorrectly, while errors of commission involve leaving out necessary information.

False Signup and view all the answers

Adverse drug reactions (ADRs) are the same as medication errors.

False Signup and view all the answers

Many state boards of pharmacy do not require quality assurance programs to prevent medication errors.

False Signup and view all the answers

Error investigations need to take place quickly, and many medication error reporting systems within hospitals are manual.

False Signup and view all the answers

Adverse drug reactions (ADRs) can occur as side effects from medication use.

True Signup and view all the answers

Error investigations need to take place slowly, and many medication error reporting systems within hospitals are electronic.

False Signup and view all the answers

Medication errors, adverse drug reactions, hazardous conditions, and near misses do not need to be reported to prevent similar errors in the future.

False Signup and view all the answers

Institutions should not have a plan in place for responding to medication errors.

False Signup and view all the answers

Match the following methods to reduce medication errors with their descriptions:

Tall man letters = Draws attention to dissimilarities in drug names Electronic prescribing = Virtually eliminates errors associated with poor handwriting Abbreviation avoidance = Unsafe and contributes to many medical errors High-alert medications = Drugs with a heightened risk of causing significant patient harm if used in error Signup and view all the answers

Match the following abbreviations with their recommended alternatives:

U (unit) = Write "unit" (zero), the number "4" (four) or "cc" IU (International Unit) = Write "International Unit" qod (every other day) = Write "daily" MS (morphine sulfate) = Write "morphine sulfate" Signup and view all the answers

Match the following medication error prevention methods with their descriptions:

Look-alike, sound-alike medications = Common cause of medication errors Drug dictionaries within computer systems = Have alerts that prompt the provider to confirm the correct medication Limiting concentrations available in high-alert medications = Method to use high-alert medications safely Failure Mode and Effects Analysis (FMEA) = Proactive method used to reduce the frequency and consequences of errors Signup and view all the answers

Match the following medication error prevention methods with their purposes:

Medication reconciliation = Maintain accurate patient medication information Reporting critical results of tests and diagnostic procedures = Related to NPSGs goals Quality assurance programs = Prevent medication errors and mandate reporting errors to patients and prescribers ISMP National Medication Errors Reporting Program (MERP) = Confidential national voluntary reporting program for medication errors Signup and view all the answers

Match the following organizations with their involvement in improving medication safety:

Institute of Medicine (IOM) = Found up to 98,000 Americans die each year due to preventable medical errors The Joint Commission (TJC) = Actively involved in improving medication safety Institute for Safe Medication Practices (ISMP) = Actively involved in improving medication safety State boards of pharmacy = Require quality assurance programs to prevent medication errors and mandate reporting errors to patients and prescribers Signup and view all the answers

Match the following terms with their definitions:

Sentinel events = Unexpected occurrences involving death or serious injury, require investigation and measures to prevent recurrence Errors of omission = Involve leaving out necessary information, compromising patient safety Errors of commission = Involve doing something incorrectly, compromising patient safety Adverse drug reactions (ADRs) = Different from medication errors and can occur as side effects from medication use Signup and view all the answers

Match the following actions with their purpose in responding to medication errors:

Reporting errors = To prevent similar errors in the future Error investigations = Need to take place quickly Institutions informing committees = Of any errors for improvement Having a plan in place = For internal and external notification, disclosure, investigation, and improvement Signup and view all the answers

Match the following statements with their correct information on medication errors:

System-based causes = Most common cause of medication errors according to experts Trailing zero (X.O mg) = Considered problematic Lack of leading zero (X mg) = Considered problematic Abbreviation 'MS' = Considered problematic Signup and view all the answers

Match the following medication safety and quality improvement programs with their descriptions:

ISMP National Medication Errors Reporting Program (MERP) = Confidential national voluntary reporting program for medication errors Root Cause Analysis (RCA) = Retrospective investigation of an event used to design changes to prevent future errors Failure Mode and Effects Analysis (FMEA) = Proactive method used to reduce the frequency and consequences of errors The Joint Commission on Accreditation of Healthcare Organizations (TJC) = Accredits and certifies healthcare organizations and sets National Patient Safety Goals (NPSGs) Signup and view all the answers

Match the following National Patient Safety Goals (NPSGs) with their focus areas:

Using at least two patient identifiers when providing care, treatment, and services = Patient identification and safety Reporting critical results of tests and diagnostic procedures on a timely basis, and labeling all medications and containers = Timely reporting and medication labeling Reducing the likelihood of harm associated with anticoagulant therapy and maintaining accurate patient medication information = Anticoagulant therapy and medication information Implementing evidence-based practices to reduce healthcare-associated infections, including multidrug-resistant organisms = Healthcare-associated infections and prevention Signup and view all the answers

Match the following medication error investigation methods with their characteristics:

Root Cause Analysis (RCA) = Retrospective investigation of an event used to design changes to prevent future errors Failure Mode and Effects Analysis (FMEA) = Proactive method used to reduce the frequency and consequences of errors Confidential national voluntary reporting program for medication errors = ISMP National Medication Errors Reporting Program (MERP) Proactive investigation of an event that has occurred, used to design changes to prevent future errors = Root Cause Analysis (RCA) Signup and view all the answers

Match the following medication safety and quality improvement programs with their roles:

ISMP National Medication Errors Reporting Program (MERP) = Encourages professionals and consumers to report medication errors, even if reported internally Root Cause Analysis (RCA) = Retrospective investigation of an event used to design changes to prevent future errors The Joint Commission on Accreditation of Healthcare Organizations (TJC) = Conducts on-site surveys for accredited organizations and sets National Patient Safety Goals (NPSGs) annually Failure Mode and Effects Analysis (FMEA) = Proactively used to reduce the frequency and consequences of errors Signup and view all the answers

Which of the following is considered a high-alert medication?

Insulins Signup and view all the answers

What is a key precaution for the use of Insulin U-500?

Specify conditions for its use Signup and view all the answers

Which of the following is an example of a chemotherapeutic drug?

Methotrexate Signup and view all the answers

What is the purpose of protocols for high-risk drugs?

To reduce the chance of errors from inappropriate prescribing Signup and view all the answers

Which method is crucial in medication error reduction, tracking the drug from the pharmacy to the patient?

Automated dispensing cabinets (ADCs) Signup and view all the answers

What is the recommended daily dose limit for Citalopram due to potential heart-related issues?

40 mg Signup and view all the answers

What is the primary role of barcode technology in medication administration?

Track the drug from the pharmacy to the patient Signup and view all the answers

Which technology automates drug inventory, improves controlled drug security, and provides usage reports?

Automated dispensing cabinets (ADCs) Signup and view all the answers

What is the primary purpose of barcode scanning in medication administration?

Track the drug from the pharmacy to the patient Signup and view all the answers

Which tool is used in medication administration to ensure the 'five rights'?

Barcode technology Signup and view all the answers

What is the primary role of Computerized prescriber order entry (CPOE) in medication safety?

Reduce errors Signup and view all the answers

What is the primary role of staff education programs in medication safety?

Reduce errors Signup and view all the answers

What is the primary role of monitoring for drug-food interactions in medication safety?

Reduce errors Signup and view all the answers

What is the primary role of barcode technology in medication error reduction?

Reduce errors Signup and view all the answers

What is the primary role of Automated dispensing cabinets (ADCs) in medication safety?

Reduce errors Signup and view all the answers

What is the primary role of clinical decision support (CDS) tools in medication safety?

Reduce errors Signup and view all the answers

High-alert medications are only found in acute care settings and not in community/ambulatory or long-term care settings.

False Signup and view all the answers

Insulin U-500 is an example of a high-alert medication.

True Signup and view all the answers

Protocols for high-risk drugs can reduce the chance of errors from inappropriate prescribing.

True Signup and view all the answers

Institutions should stock high-alert products only in the pharmacy to ensure safe use.

True Signup and view all the answers

Consultant pharmacists are not involved in medication reviews and ordering medication discontinuation

False Signup and view all the answers

Prescribers should use the imperial system to express all weights, volumes, and units

False Signup and view all the answers

Look-alike packaging cannot contribute to errors, and medications can be identified based on packaging alone

False Signup and view all the answers

A code blue refers to a patient requiring routine medical care

False Signup and view all the answers

Pharmacists working in high-risk areas cannot assist in identifying and preventing medication errors

False Signup and view all the answers

The 'five rights' of medication administration include right patient, right drug, right dose, right route, and right time

True Signup and view all the answers

Indications for use on prescriptions do not help pharmacists ensure appropriate prescribing and drug selection

False Signup and view all the answers

Multiple-dose vials do not pose risks for cross-contamination and overdosing

False Signup and view all the answers

Safe practices for emergency medications/crash carts do not include proper training, unit dose and age-specific medications, and monitoring drug expiration dates

False Signup and view all the answers

Patients cannot play a vital role in preventing medication errors by asking questions and seeking satisfactory answers about their medications

False Signup and view all the answers

An error due to misidentification of a concentration based on the packaging resulted in an overdose of heparin in a NICU unit

True Signup and view all the answers

Failure Mode and Effects Analysis (FMEA) is a prospective method used to reduce the frequency and consequences of errors

False Signup and view all the answers

Medication Therapy Management (MTM) primarily targets patients with a single chronic condition, aiming to reduce medication costs.

False Signup and view all the answers

Medication reconciliation should only be done at hospital discharge to ensure a smooth transition to home medications.

False Signup and view all the answers

Medication reconciliation involves developing a list of current medications, a list of medications to be prescribed, comparing the two lists, noting discrepancies, and communicating the new list to appropriate caregivers and the patient.

True Signup and view all the answers

Medication reconciliation is not important in ambulatory care settings, as patients usually receive prescriptions from a single outpatient provider.

False Signup and view all the answers

MTM initiatives focus on improving nonadherence, identifying cost-savings, and addressing missed therapies.

True Signup and view all the answers

Medication reconciliation is crucial for patient safety and effective medication management in healthcare settings.

True Signup and view all the answers

Potassium Chloride (KCI) vials should be removed from floor stock, and protocols for KCI delivery should be followed in hospitals.

True Signup and view all the answers

Insulin infusions should be standardized to one concentration and protocols developed for their management in hospitals.

True Signup and view all the answers

Medication reconciliation compares a patient's medication orders with all medications they have been taking to avoid errors and is now usually performed within the electronic health record (EHR).

True Signup and view all the answers

Medication reconciliation should be done at every transition of care, including hospital admission, transfer, and discharge.

True Signup and view all the answers

Medication reconciliation addresses the patient's home medications and educates them about the medications used during hospitalization.

True Signup and view all the answers

MTM targets patients with multiple chronic conditions and high medication costs, using computer databases to identify high-risk patients.

True Signup and view all the answers

What is the purpose of medication reconciliation?

To compare a patient’s medication orders to all of the medications that the patient has been taking to avoid errors Signup and view all the answers

What does Medication Therapy Management (MTM) aim to improve?

Nonadherence in heart failure patients Signup and view all the answers

What is the role of a pharmacist in Medication Therapy Management (MTM)?

To review profiles for proper use of medications Signup and view all the answers

What is the focus of medication reconciliation during transitions of care?

To compare the medications on two lists and note discrepancies Signup and view all the answers

What is the purpose of developing a list of current medications during medication reconciliation?

To compare a patient’s medication orders to all of the medications that the patient has been taking to avoid errors Signup and view all the answers

What is the purpose of Medication Therapy Management (MTM)?

To improve nonadherence in heart failure patients Signup and view all the answers

What is the focus of Medication Therapy Management (MTM) in identifying patients for intervention?

To identify patients with multiple chronic conditions who are taking multiple drugs and are likely to incur annual costs for covered drugs that exceed a predetermined level Signup and view all the answers

What is the role of pharmacists in identifying patients for Medication Therapy Management (MTM)?

To review profiles for proper use of medications Signup and view all the answers

What is the purpose of developing a list of medications to be prescribed during medication reconciliation?

To develop a list of current medications Signup and view all the answers

What is the focus of medication reconciliation during hospital discharge?

To compare the medications on two lists and note discrepancies Signup and view all the answers

What is the primary focus of medication therapy management (MTM)?

Comprehensive medication review Signup and view all the answers

What is the primary purpose of medication reconciliation?

To compare a patient’s medication orders to all of the medications the patient has been taking Signup and view all the answers

What is the recommended approach for medication reconciliation during hospital discharge?

Continuing all medications used during hospitalization Signup and view all the answers

What is the recommended action for handling Potassium Chloride (KCI) vials?

Removing KCI vials from floor stock Signup and view all the answers

When is automatic substitution of oral KCI for IV KCI allowed?

When appropriate Signup and view all the answers

What is the purpose of placing high-risk drugs in a medication bin with a visual alert?

To prevent dispensing errors Signup and view all the answers

What is the role of computer databases in medication safety?

To identify high-risk patients Signup and view all the answers

Why should insulin always be labeled with “units” and not “U”?

To prevent automated dispensing Signup and view all the answers

What is the purpose of using the metric system to express all weights, volumes, and units in prescriptions?

To ensure accurate and standardized measurements Signup and view all the answers

What is the significance of the 'five rights' of medication administration?

To prevent medication errors Signup and view all the answers

Why is it important for patients to ask questions and seek satisfactory answers about their medications?

To prevent medication errors Signup and view all the answers

What is the role of pharmacists working in high-risk areas like the ICU, pediatric units, and emergency departments?

To identify and prevent medication errors Signup and view all the answers

Why should medications not be identified based on packaging alone?

Packaging can be misleading Signup and view all the answers

What is the purpose of designating multiple-dose vials for a single patient and labeling them appropriately?

To minimize the risk of cross-contamination and overdosing Signup and view all the answers

What does a code blue refer to in a healthcare setting?

A patient requiring emergency medical care Signup and view all the answers

What is the purpose of safe practices for emergency medications/crash carts?

To prevent errors in emergency medication management Signup and view all the answers

What is the role of the consultant pharmacist in medication safety?

To conduct medication reviews and recommend changes Signup and view all the answers

Why is it important for prescribers to include indications for use on prescriptions?

To assist pharmacists in ensuring appropriate prescribing Signup and view all the answers

What is the significance of using unit dose and age-specific medications in emergency settings?

To ensure appropriate dosing for different patient populations Signup and view all the answers

Why is it crucial for medications to be expressed in the metric system?

To ensure accurate and standardized measurements Signup and view all the answers

Barcode technology in medication administration automates the medication administration record, saving time.

True Signup and view all the answers

Citalopram should not be used at doses greater than 40 mg per day due to potential heart-related issues.

True Signup and view all the answers

Barcoding is a crucial tool in medication error reduction, tracking the drug from the pharmacy to the patient.

True Signup and view all the answers

Computerized prescriber order entry (CPOE) reduces errors and clinical decision support (CDS) tools improve its effectiveness.

True Signup and view all the answers

Automated dispensing cabinets (ADCs) automate drug inventory, improve controlled drug security, and provide usage reports.

True Signup and view all the answers

Barcode scanning improves ADC safety by ensuring the right drug is pulled and administered to the right patient.

True Signup and view all the answers

The 'five rights' of medication administration include right patient, right drug, right dose, right route, and right time.

True Signup and view all the answers

Monitoring for drug-food interactions is crucial, especially with high-risk medications and enteral feedings.

True Signup and view all the answers

Barcode scanning improves ADC safety by ensuring the right drug is pulled and administered to the right patient.

True Signup and view all the answers

Barcoding ensures the right drug is stocked and administered to the right patient at the right time.

True Signup and view all the answers

Staff education programs, free from bias, are essential when introducing new high-alert drugs or procedural changes.

True Signup and view all the answers

Barcoding provides alerts and works well with ADCs, and their use requires pharmacist review and oversight.

False Signup and view all the answers

Barcoding is the only error prevention method necessary in medication safety.

False Signup and view all the answers

Citalopram should not be used at doses greater than 40 mg per day due to potential heart-related issues.

True Signup and view all the answers

Automated dispensing cabinets (ADCs) do not require pharmacist review and oversight.

False Signup and view all the answers

Barcode scanning does not improve ADC safety by ensuring the right drug is pulled and administered to the right patient.

False Signup and view all the answers

Computerized prescriber order entry (CPOE) does not reduce errors.

False Signup and view all the answers

Barcode technology in medication administration does not automate the medication administration record, saving time.

False Signup and view all the answers

Monitoring for drug-food interactions is not crucial, especially with high-risk medications and enteral feedings.

False Signup and view all the answers

Barcoding is not a crucial tool in medication error reduction, tracking the drug from the pharmacy to the patient.

False Signup and view all the answers

Barcoding does not ensure the right drug is stocked and administered to the right patient at the right time.

False Signup and view all the answers

Staff education programs, free from bias, are not essential when introducing new high-alert drugs or procedural changes.

False Signup and view all the answers

Barcoding does not work well with automated dispensing cabinets (ADCs).

False Signup and view all the answers

The "five rights" in medication safety should be used alone without combining with other error prevention methods.

False Signup and view all the answers

Match the high alert medication with its category:

Propofol = Anesthetics, IV or inhaled Amiodarone = Antiarrhythmics, IV Methotrexate = Chemotherapeutics Insulin U-500 = Insulins Signup and view all the answers

Match the medication safety precaution with its example:

Insulin = Specify conditions under which it is to be used Potassium chloride = Protocols for high risk drugs Signup and view all the answers

Match the medication error prevention measure with its purpose:

Stocking high-alert products only in the pharmacy = Reduce the chance of errors from inappropriate prescribing Placing high-risk drugs in a medication bin with a visual alert = Increase appropriate prescribing Signup and view all the answers

Match the medication error investigation method with its characteristic:

Root Cause Analysis (RCA) = Proactive investigation of an event that has occurred, used to design changes to prevent future errors Failure Mode and Effects Analysis (FMEA) = Retrospective method used to reduce the frequency and consequences of errors Signup and view all the answers

Match the following medication safety practices with their descriptions:

Look-alike packaging = Can contribute to errors and medications should not be identified based on packaging alone Multiple-dose vials = Pose risks for cross-contamination and overdosing and should ideally be designated for a single patient and labeled appropriately Safe practices for emergency medications/crash carts = Include proper training, unit dose and age-specific medications, and monitoring drug expiration dates Code blue = Refers to a patient requiring emergency medical care, typically for cardiac or respiratory arrest Signup and view all the answers

Match the following medication error prevention measures with their descriptions:

Patients' role in preventing medication errors = Can play a vital role by asking questions and seeking satisfactory answers about their medications Pharmacists' role in high-risk areas = Can assist in identifying and preventing medication errors in areas like the ICU, pediatric units, and emergency departments The 'five rights' of medication administration = Include right patient, right drug, right dose, right route, and right time, and can help prevent medication errors Prescribers using the metric system = Should express all weights, volumes, and units to ensure safe prescribing Signup and view all the answers

Match the following medication-related incidents with their outcomes:

Discontinuation of atenolol = Ordered after discussion with the physician during a medication review at transitional care Misidentification of a concentration based on packaging = Resulted in an overdose of heparin in a NICU unit Adverse event due to multiple-dose vials = Posed risks for cross-contamination and overdosing Use of tall man letters in drug names = Recommended to reduce confusion between similar drug names Signup and view all the answers

Match the medication safety method with its description:

The 'five rights' combined with other error prevention methods = Best practice in medication safety Barcoding in medication administration = Technological tool to ensure the 'five rights' Monitoring for drug-food interactions = Crucial, especially with high-risk medications and enteral feedings Staff education programs free from bias = Essential when introducing new high-alert drugs or procedural changes Signup and view all the answers

Match the technology/tool with its role in medication safety:

Computerized prescriber order entry (CPOE) = Reduces errors Clinical decision support (CDS) tools = Improves CPOE effectiveness Barcode technology in medication administration = Automates medication administration record, saving time Automated dispensing cabinets (ADCs) = Automate drug inventory, improve controlled drug security, and provide usage reports Signup and view all the answers

Match the statement about Citalopram with its accurate information:

Citalopram should not be used at doses greater than 40 mg per day = Due to potential heart-related issues Citalopram should not be used at doses greater than 20 mg per day = Due to potential liver-related issues Citalopram should not be used at doses greater than 30 mg per day = Due to potential kidney-related issues Citalopram should not be used at doses greater than 50 mg per day = Due to potential lung-related issues Signup and view all the answers

Match the role of barcoding in medication safety with its description:

Tracking the drug from the pharmacy to the patient = Crucial tool in medication error reduction Automating medication administration record = Saving time Ensuring the right drug is stocked and administered to the right patient at the right time = Role in medication error reduction Improving ADC safety by ensuring the right drug is pulled and administered to the right patient = Role in ADC safety Signup and view all the answers

Match the following medication safety protocols with their descriptions:

Insulin infusions concentration standardization = Standardizing insulin infusions to one concentration Medication Therapy Management (MTM) = Involves comprehensive medication review and development of a medication-related action plan Medication reconciliation = Involves comparing a patient’s medication orders to all of the medications the patient has been taking Potassium Chloride (KCI) infusions preparation = Prepared in the pharmacy with specific delivery protocols Signup and view all the answers

Match the following Medication Therapy Management (MTM) initiatives with their goals:

MTM targets = Patients with multiple chronic conditions and high medication costs MTM initiatives aim to = Improve nonadherence and identify cost-savings Medication reconciliation = Should be done at every transition of care Discharge medication reconciliation = Opportunity to address home medications and educate the patient Signup and view all the answers

Match the following medication safety precautions with their recommendations:

Insulin labeling = Should always be labeled with “units” or "units = mL", never just "mL" Insulin storage = Should not be placed in automated dispensing cabinets Medication reconciliation = Now usually performed within the electronic health record (EHR) Potassium Chloride (KCI) infusions = Should be prepared in the pharmacy with specific delivery protocols Signup and view all the answers

Match the following medication safety processes with their purposes:

Medication Therapy Management (MTM) = Involves comprehensive medication review and development of a medication-related action plan Medication reconciliation = Involves comparing a patient’s medication orders to all of the medications the patient has been taking Potassium Chloride (KCI) infusions preparation = Prepared in the pharmacy with specific delivery protocols Insulin labeling = Should always be labeled with “units” or "units = mL", never just "mL" Signup and view all the answers

What is the primary purpose of using computerized alerts for high-risk medications in Automated Dispensing Cabinets (ADCs)?

To reduce error risk associated with selecting high-risk medications Signup and view all the answers

Why should certain medications like insulin, warfarin, and high-dose narcotics not be placed in Automated Dispensing Cabinets (ADCs)?

They require special storage conditions Signup and view all the answers

What is the primary benefit of using Patient Controlled Analgesia (PCA) devices for opioid administration?

To reduce the risk of over-sedation Signup and view all the answers

In what way can the environment affect the accuracy of medication administration using Automated Dispensing Cabinets (ADCs)?

Noise and poor lighting can increase the risk of errors Signup and view all the answers

Which type of hand soap is recommended for reducing infections in healthcare facilities?

Antimicrobial hand soaps with chlorhexidine Signup and view all the answers

Why are alcohol-based hand rubs not effective in certain situations?

They do not kill certain infections Signup and view all the answers

What should never be administered intravenously to avoid fatal errors?

Oral solutions/suspensions Signup and view all the answers

What is recommended for proper disposal of needles and sharps?

FDA-cleared sharps containers Signup and view all the answers

When is handwashing with soap and water recommended?

When hands are visibly soiled Signup and view all the answers

What can lead to outbreaks of blood-borne pathogens and other microbial infections?

Unsafe injection practices Signup and view all the answers

What is crucial before and after patient contact, donning and removing gloves, and handling invasive devices?

Hand hygiene Signup and view all the answers

What is the recommended soap for reducing infections in healthcare facilities?

Antimicrobial hand soaps with chlorhexidine Signup and view all the answers

What is not effective in certain situations, such as when hands are visibly soiled or when caring for patients with certain infections?

Alcohol-based hand rubs Signup and view all the answers

What is not recommended for reducing infections in healthcare facilities?

Regular hand soaps Signup and view all the answers

What is crucial for reducing infections in healthcare facilities?

Hand hygiene Signup and view all the answers

What is not effective for reducing infections in healthcare facilities?

Alcohol-based hand rubs Signup and view all the answers

What is a key factor contributing to the risk of respiratory depression with PCA usage?

Concurrent use of CNS depressants Signup and view all the answers

Which infection control precaution is recommended for diseases like influenza?

Droplet precautions Signup and view all the answers

What is a significant issue related to hospital-acquired infections?

Avoidable illness and death Signup and view all the answers

What is crucial in reducing the spread of nosocomial infections in healthcare settings?

Proper cleaning of surfaces Signup and view all the answers

What is recommended to minimize catheter-related bloodstream infections?

Utilizing skin antiseptics Signup and view all the answers

What is a common hospital-acquired infection mentioned in the text?

Hepatitis Signup and view all the answers

What is a requirement for administering PCA doses, as per The Joint Commission?

Well-coordinated healthcare teams Signup and view all the answers

What measure is recommended for safety of PCAs?

Standard order sets Signup and view all the answers

What is a key organism mentioned in the context of infection control?

Norovirus Signup and view all the answers

What is the role of Medicare in relation to hospital-acquired infections?

Refusing reimbursement Signup and view all the answers

What is a factor contributing to the complexity of PCA devices?

High risk of medication errors Signup and view all the answers

What is a significant requirement for infection control in healthcare settings?

Proper cleaning of surfaces Signup and view all the answers

Match the following medication safety precautions with their recommendations:

Storing look-alike, sound-alike medications in different locations within the ADC = Reduce error risk by using computerized alerts and requiring confirmation for high-risk medications Not permitting nurses to put medications back into the medication compartment = Have a separate drawer for all "returned" medications to prevent placement in the wrong area Avoiding putting certain medications like insulin, warfarin, and high-dose narcotics into the ADCs = Prevent errors by keeping these medications out of the automated dispensing cabinets Considering environmental factors like noise and lighting when using automated dispensing cabinets (ADCs) = Errors increase in busy, noisy environments with poor lighting, so precautions should be taken Signup and view all the answers

Match the following medication safety protocols with their descriptions:

Patient Controlled Analgesia (PCA) devices = Allow patients to treat pain quickly and administer small doses to reduce side effects High-risk drugs protocols = Reduce the chance of errors from inappropriate prescribing by implementing specific protocols Medication reconciliation during hospital discharge = Recommended approach to ensure accuracy and safety in transitioning care settings Monitoring for drug-food interactions = Crucial in ensuring patient safety, especially with high-risk medications and enteral feedings Signup and view all the answers

Match the following medication safety and quality improvement programs with their descriptions:

The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) = Actively involved in improving medication safety through various initiatives and guidelines Computerized prescriber order entry (CPOE) = Plays a primary role in medication safety by reducing errors associated with handwritten prescriptions and improving order accuracy Clinical decision support (CDS) tools = Primary role is to assist healthcare providers in making safe and effective medication-related decisions Failure Mode and Effects Analysis (FMEA) = Prospective method used to identify and reduce the frequency and consequences of errors in medication processes Signup and view all the answers

Match the following safe practices for emergency medications with their purposes:

Using patient controlled analgesia (PCA) devices for post-surgical pain = Allows patients to quickly treat pain and administer small doses to reduce side effects Proper training, unit dose and age-specific medications, and monitoring drug expiration dates for emergency medications/crash carts = Ensures safe and effective administration of emergency medications to patients in critical situations Limiting concentrations available in high-alert medications = Reduces the risk of errors by limiting the available concentrations of high-alert medications Informing Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee of any errors related to emergency medications = Ensures that errors are reported and addressed to improve emergency medication safety Signup and view all the answers

Match the following hand hygiene products with their features:

Antimicrobial hand soaps with chlorhexidine = Recommended for reducing infections in healthcare facilities Triclosan = Effective but raises environmental concerns due to water supply contamination Alcohol-based hand rubs = Not effective in certain situations, such as when hands are visibly soiled or when caring for patients with certain infections Handwashing with soap and water = Physically removes spores and is recommended in specific cases Signup and view all the answers

Match the following hand hygiene practices with their importance:

Hand hygiene before and after patient contact = Crucial in reducing infections in healthcare facilities Hand hygiene before and after donning and removing gloves = Crucial in reducing infections in healthcare facilities Hand hygiene before and after handling invasive devices = Crucial in reducing infections in healthcare facilities Hand hygiene with alcohol-based hand rubs = Outlined for healthcare workers and not effective in certain situations Signup and view all the answers

Match the following safe injection practices with their purpose:

Single-dose vials, engineered sharps protection, and proper disposal of needles and sharps = Safety measures to prevent outbreaks of blood-borne pathogens and other microbial infections FDA-cleared sharps containers for proper disposal = Recommended for patients using injectable medications Recapping needles only when a sharps container is not immediately available = Permitted with specific one-hand methods outlined Local trash removal services or health departments = Provide information on sharps disposal guidelines and programs Signup and view all the answers

Match the infection control measure with its purpose:

Proper hand hygiene = Reducing the spread of nosocomial infections Contact precautions for MRSA and VRE = Preventing the transmission of specific pathogens Minimizing catheter-related bloodstream infections = Reducing the risk of bloodstream infections Barcoding technology = Ensuring the right drug is administered to the right patient Signup and view all the answers

Match the infection control precautions with the corresponding diseases:

Contact precautions = MRSA and VRE Droplet precautions = Influenza Airborne precautions = Tuberculosis and varicella virus Standard order sets = Limiting opioids in floor stock Signup and view all the answers

Match the hospital-acquired infections with their sources:

Indwelling catheters = Common source of hospital-acquired infections IV lines = Common source of hospital-acquired infections Surgical sites = Common source of hospital-acquired infections Friends and family members = Not allowed to administer PCA doses Signup and view all the answers

Match the safety measures for PCAs with their purposes:

Limiting opioids in floor stock = Safety measure for PCAs Using standard order sets = Safety measure for PCAs Implementing protocols with independent double-checking = Safety measure for PCAs Aseptic technique during insertion = Minimizing catheter-related bloodstream infections Signup and view all the answers

Match the factors contributing to respiratory depression with PCA usage with the corresponding risks:

Advanced age = Increased risk of respiratory depression with PCA usage Obesity = Increased risk of respiratory depression with PCA usage Concurrent use of CNS depressants = Increased risk of respiratory depression with PCA usage Cooperative and cognitively assessed patients = Requirement for administering PCA treatment Signup and view all the answers

Match the significant issue with its impact:

Hospital-acquired infections = Almost 2 million occurring annually Medication errors = Leading to preventable errors Proper hand hygiene = Essential to prevent the spread of organisms Patient Controlled Analgesia (PCA) devices = Complex and require setup and programming Signup and view all the answers

True or false: Look-alike, sound-alike medications should be stored in the same location within the ADC.

False Signup and view all the answers

True or false: Using computerized alerts can help reduce error risk when selecting medications with high potential for mix-up.

True Signup and view all the answers

True or false: Nurses should be permitted to put medications back into the medication compartment for easy access.

False Signup and view all the answers

True or false: Patient Controlled Analgesia (PCA) devices are not effective for treating post-surgical pain.

False Signup and view all the answers

Patient Controlled Analgesia (PCA) devices are simple and do not require setup and programming, reducing medication errors.

False Signup and view all the answers

PCA treatment can be administered by friends and family members if the patient is unable to do so.

False Signup and view all the answers

Hospital-acquired infections do not result in financial costs for healthcare facilities.

False Signup and view all the answers

Medicare does not have the authority to refuse reimbursement for hospital-acquired infections.

False Signup and view all the answers

Infection control measures are not essential in preventing the spread of organisms in healthcare settings.

False Signup and view all the answers

Minimizing catheter-related bloodstream infections does not involve aseptic technique during insertion.

False Signup and view all the answers

Proper hand hygiene is not crucial in reducing the spread of nosocomial infections in healthcare settings.

False Signup and view all the answers

Almost 2 million hospital-acquired infections occur annually, leading to unavoidable illness, death, and financial costs.

True Signup and view all the answers

States do not require hospitals to report infection rates.

False Signup and view all the answers

Proper hand hygiene includes the use of alcohol-based hand rubs to reduce the spread of nosocomial infections in healthcare settings.

True Signup and view all the answers

Hospital-acquired infections can result from indwelling catheters, IV lines, surgical sites, decubitus ulcers, hepatitis, C. difficile, and pneumonia.

True Signup and view all the answers

The risk of respiratory depression with PCA usage does not increase with advanced age, obesity, and concurrent use of CNS depressants.

False Signup and view all the answers

Alcohol-based hand rubs are always effective in reducing infections in healthcare facilities.

False Signup and view all the answers

Oral solutions/suspensions can be safely administered intravenously without risk of fatal errors.

False Signup and view all the answers

Triclosan raises environmental concerns due to water supply contamination.

True Signup and view all the answers

Hand hygiene is only crucial after patient contact, not before.

False Signup and view all the answers

Recapping needles is generally permitted in healthcare facilities.

False Signup and view all the answers

Using single-dose vials is a safety measure for preventing outbreaks of blood-borne pathogens.

True Signup and view all the answers

Patients using injectable medications should not have FDA-cleared sharps containers for proper disposal.

False Signup and view all the answers

Unsafe injection practices cannot lead to outbreaks of blood-borne pathogens.

False Signup and view all the answers

Alcohol-based hand rubs are not effective when caring for patients with certain infections.

True Signup and view all the answers

Proper handwashing techniques are not outlined for healthcare workers.

False Signup and view all the answers

Triclosan is not effective in reducing infections in healthcare facilities.

False Signup and view all the answers

Handwashing with soap and water physically removes spores and is recommended in specific cases.

True Signup and view all the answers

Alcohol-based hand rubs are not effective in certain situations, such as when hands are visibly soiled or when caring for patients with certain infections.

True Signup and view all the answers

Triclosan is effective but raises environmental concerns due to water supply contamination.

False Signup and view all the answers

Hand hygiene is crucial before and after patient contact, donning and removing gloves, and handling invasive devices.

True Signup and view all the answers

Antimicrobial hand soaps with chlorhexidine (Hibiclens, others) are recommended for reducing infections in healthcare facilities.

True Signup and view all the answers

Patients using injectable medications should have FDA-cleared sharps containers for proper disposal.

True Signup and view all the answers

Unsafe injection practices can lead to outbreaks of blood-borne pathogens and other microbial infections.

True Signup and view all the answers

Local trash removal services or health departments can provide information on sharps disposal guidelines and programs.

True Signup and view all the answers

Recapping needles is only permitted when a sharps container is not immediately available, and specific one-hand methods are outlined.

True Signup and view all the answers

Oral solutions/suspensions should never be administered intravenously to avoid fatal errors.

True Signup and view all the answers

Handwashing with soap and water physically removes spores and is recommended in specific cases.

True Signup and view all the answers

Proper handwashing techniques and alcohol-based hand rub application are outlined for healthcare workers.

True Signup and view all the answers

Safety measures include using single-dose vials, engineered sharps protection, and proper disposal of needles and sharps.

True Signup and view all the answers

What is the purpose of using 'Tall Man Lettering' for high-alert drugs?

Tall Man Lettering is used to differentiate look-alike drug names and reduce the risk of medication errors. Signup and view all the answers

Why is medication reconciliation important during transitions of care?

Medication reconciliation is important to ensure accurate and complete medication information is obtained and communicated during transitions of care, reducing the risk of medication errors. Signup and view all the answers

What is the role of Computerized Prescriber Order Entry (CPOE) in medication safety?

CPOE helps reduce medication errors by allowing electronic entry of medication orders, providing decision support, and facilitating communication among healthcare team members. Signup and view all the answers

What are some methods to reduce medication errors?

Methods to reduce medication errors include avoiding 'Do Not Use' abbreviations, using Tall Man Lettering, medication reconciliation, proper prescription indications and instructions, and employing technology and automated systems. Signup and view all the answers

Explain the purpose and function of the ISMP National Medication Errors Reporting Program (MERP).

The ISMP National Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program that analyzes system causes of medication errors and provides recommendations for prevention. Signup and view all the answers

What is the primary focus of NPSG 03.05.01?

NPSG 03.05.01 focuses on reducing the likelihood of harm associated with anticoagulant therapy. Signup and view all the answers

What is the role of the Joint Commission on Accreditation of Healthcare Organizations (TJC) in healthcare?

TJC accredits and certifies healthcare organizations, setting standards for quality and safety of care, and sets annual National Patient Safety Goals (NPSGs) with defined measures for different healthcare settings. Signup and view all the answers

Explain the purpose of Root Cause Analysis (RCA) in healthcare.

Root cause analysis (RCA) is a retrospective investigation of an event to design changes that will prevent future errors. Signup and view all the answers

What is the significance of NPSG 01.01.01 in healthcare practices?

NPSG 01.01.01 requires using at least two patient identifiers when providing care, treatment, and services. Signup and view all the answers

What is the proactive method used to reduce the frequency and consequences of errors in healthcare?

Failure mode and effects analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors. Signup and view all the answers

How does the ISMP website facilitate medication error reporting?

Medication errors and close calls can be reported on the ISMP website, even if they were reported internally, and when there are many reports of a particular error, the manufacturer may be required to take measures to increase safety. Signup and view all the answers

What is the emphasis of NPSG 03.06.01 in healthcare practices?

NPSG 03.06.01 emphasizes maintaining and communicating accurate patient medication information. Signup and view all the answers

What is the recommended approach for handling corrective measures in error prevention?

Targeting corrective measures at the identified root cause is the best way to prevent similar problems from occurring in the future. Signup and view all the answers

Explain the function of Failure Mode and Effects Analysis (FMEA) in healthcare.

Failure mode and effects analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors. Signup and view all the answers

What is the role of the ISMP National Medication Errors Reporting Program (MERP) in medication error prevention?

ISMP National Medication Errors Reporting Program (MERP) analyzes system causes of medication errors and provides recommendations for prevention. Signup and view all the answers

Give an example of a method to reduce medication errors that involves using tall man letters.

Using tall man letters, which mix upper and lower case letters, draws attention to the dissimilarities in the drug names. Signup and view all the answers

What is the purpose of tall man letters in medication safety?

The purpose of tall man letters is to reduce confusion between similar drug names by drawing attention to the dissimilarities in the names. Signup and view all the answers

What is the significance of 'Do Not Use' abbreviations in medication safety?

Abbreviations are unsafe and contribute to many medical errors, so 'Do Not Use' abbreviations are recommended to prevent medication errors. Signup and view all the answers

What is the role of electronic prescribing in medication safety?

Electronic prescribing can virtually eliminate errors associated with poor handwriting, thereby improving medication safety. Signup and view all the answers

What is the purpose of high-alert designation for certain drugs in medication safety?

Drugs with a heightened risk of causing significant patient harm if used in error should be designated as high-alert to draw attention to their high risk and ensure extra caution in their use. Signup and view all the answers

How can high-alert medications be used safely in healthcare settings?

High-alert medications can be used safely by developing protocols or order sets for use, using premixed products whenever possible, and limiting concentrations available in healthcare settings. Signup and view all the answers

What are some examples of 'Do Not Use' abbreviations and their recommended alternatives?

Examples include using 'unit' instead of 'U' for 'unit', writing 'International Unit' instead of 'IU', and writing 'daily' instead of 'qd' or 'Q.D.' to avoid confusion and potential errors. Signup and view all the answers

What is the purpose of drug dictionaries within computer systems and automated dispensing cabinets (ADC) in medication safety?

The purpose is to have alerts that prompt the provider to confirm that the correct medication is being ordered or withdrawn, thereby reducing the risk of medication errors. Signup and view all the answers

What are some common causes of medication errors mentioned in the text?

Look-alike, sound-alike medications, poor handwriting, and similar product labeling are mentioned as common causes of medication errors. Signup and view all the answers

How can the problem of poor handwriting be addressed in medication safety?

One way to address the problem of poor handwriting is through the use of electronic prescribing, which can virtually eliminate errors associated with poor handwriting. Signup and view all the answers

What is the role of ISMP in promoting medication safety?

ISMP, along with other safety-conscious organizations, promotes the use of tall man letters and publishes lists of error-prone abbreviations, symbols, and dosage designations to improve medication safety. Signup and view all the answers

What is the purpose of developing a list of 'Do Not Use' abbreviations in healthcare institutions?

The purpose is to have a list of abbreviations that may not be used in the facility, including those from the TJC 'Do Not Use' list and any additional abbreviations selected by the institution, to prevent medication errors. Signup and view all the answers

According to the Institute of Medicine (IOM) study, how many Americans die each year in U.S. hospitals due to preventable medical errors?

Up to 98,000 Americans Signup and view all the answers

What is the formal definition of a medication error according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)?

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. Signup and view all the answers

What is the primary cause of medication errors according to experts in medication safety?

Problem with the design of the medical system itself, not usually an individual making an error Signup and view all the answers

What is the purpose of reporting medication errors, preventable adverse drug reactions, hazardous conditions, and near misses?

So that changes can be made to the system to prevent similar errors in the future Signup and view all the answers

What should be included in an institution's plan for responding to medication errors?

Internal notification, external reporting, disclosure, investigation, improvement Signup and view all the answers

What is an example of an adverse drug reaction (ADR) that is not a medication error?

Ankle swelling as a side effect of pregabalin Signup and view all the answers

What is the ethical requirement for reporting medication errors in many states?

Errors should be reported to the patient and the prescriber as soon as possible Signup and view all the answers

What are the primary committees within a hospital that should be informed of medication errors?

Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee (or similar entity) Signup and view all the answers

What is the timeframe within which error investigations need to take place according to many states?

Often within 48 hours of the incident Signup and view all the answers

What are the two types of medication error reporting systems commonly used within hospitals?

Electronic reporting system and paper reporting system Signup and view all the answers

What is the role of the state boards of pharmacy regarding medication errors?

Require quality assurance programs to promote pharmacy processes to prevent medication errors Signup and view all the answers

What is the purpose of the Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee in a hospital?

To be informed of the error and take measures to prevent similar errors in the future Signup and view all the answers

What are the two organizations actively involved in improving medication safety in the U.S.?

Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) Signup and view all the answers

What are the two distinct types of errors involving medication use or patient harm?

Errors of omission and errors of commission Signup and view all the answers

What are the most common cause of medication errors, according to the text?

System-based causes Signup and view all the answers

What are the components of medication errors as defined in the text?

Prescribing, order communication, product labeling, dispensing, administration, and monitoring Signup and view all the answers

What type of events prompt investigation to prevent recurrence, according to the text?

Sentinel events, involving death or serious injury Signup and view all the answers

What is the emphasis of the reporting of medication errors, adverse drug reactions, and hazardous conditions according to the text?

Crucial for preventing similar incidents in the future Signup and view all the answers

What are the distinct events from medication errors that can occur without any error in prescribing or dispensing?

Adverse drug reactions (ADRs) Signup and view all the answers

What are the plans that institutions should have in response to medication errors, according to the text?

Internal notification, external reporting, disclosure, investigation, and improvement Signup and view all the answers

What are the distinct events from medication errors that can occur without any error in prescribing or dispensing?

Adverse drug reactions (ADRs) Signup and view all the answers

What committees should be informed of any medication errors, according to the text?

The hospital's Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee Signup and view all the answers

What are some examples of high-alert medications mentioned in the text?

Anesthetics, IV or inhaled (e.g., propofol), Antiarrhythmics, IV (e.g., amiodarone), Anticoagulants /Antithrombotics (e.g., heparin, warfarin), Chemotherapeutics (e.g, methotrexate), Epidural/intrathecal drugs, Hypertonic saline (greater than 0.9%), Immunosuppressants (e.g., cyclosporine), Inotropics (e.g. digoxin), Insulins (e.g., insulin aspart, insulin U- 500), Magnesium sulfate injection, Opioids, Oral hypoglycemics (e.g., sulfonylureas), Parenteral nutrition, Potassium chloride and phosphates for injection, Sterile water for injection Signup and view all the answers

What are some examples of safe-use precautions mentioned for high-alert medications?

For insulin: specifying conditions under which it is to be used and which product will be stocked (vials and U-500 syringes vs. pens). For potassium chloride: specifying the conditions under which it is to be used. Signup and view all the answers

What is the role of protocols for high-risk drugs mentioned in the text?

The role of protocols for high-risk drugs is to increase appropriate prescribing and reduce the chance of errors from inappropriate prescribing. Signup and view all the answers

What is the recommended practice regarding stocking high-alert products mentioned in the text?

The recommended practice is to centralize the institution and stock high-alert products only in the pharmacy. Signup and view all the answers

What is the significance of recording measurements in the metric system in medication prescriptions?

Recording measurements in the metric system helps to avoid errors, as many calculations and dosing checks are performed automatically based on the recorded patient data. Signup and view all the answers

How can look-alike packaging contribute to medication errors?

Look-alike packaging can contribute to errors, and it is crucial not to rely on the package to identify the right drug product. Signup and view all the answers

What are the 'five rights' of medication administration and why are they important?

The 'five rights' of medication administration are the right patient, right drug, right dose, right route, and right time. They are important to prevent medication errors. Signup and view all the answers

What are the safety measures for emergency medications and crash carts?

Safe practices for emergency medications and crash carts include properly training staff, using unit dose and age-specific medications, and monitoring drug expiration dates. Signup and view all the answers

How can pharmacists working in high-risk areas assist in preventing medication errors?

Pharmacists working in high-risk areas such as the ICU, pediatric units, and emergency departments can assist in identifying and preventing medication errors through process improvements. Signup and view all the answers

What is the purpose of designating multiple-dose vials for a single patient and labeling them appropriately?

Multiple-dose vials pose a risk for cross-contamination and over-dosing, and should ideally be designated for a single patient and labeled appropriately. Signup and view all the answers

What is the significance of patients asking questions and seeking satisfactory answers about their medications?

Patients should be encouraged to ask questions and seek satisfactory answers about their medications to prevent errors, and written information about medications should be at an appropriate reading level for the patient. Signup and view all the answers

What does a 'code blue' refer to and what actions are taken during a 'code blue' situation?

A code blue refers to a patient requiring emergency medical care, typically for cardiac or respiratory arrest. During a 'code blue' situation, the code team, often including a pharmacist, rushes to the room and begins immediate resuscitative efforts. Signup and view all the answers

Why should indications for use be written on prescriptions and why is the use of the term 'as directed' not acceptable?

Indications for use should be written on prescriptions to ensure appropriate drug selection, and the use of the term 'as directed' is not acceptable to prevent medication errors. Signup and view all the answers

What are the risks associated with using look-alike packaging and multiple-dose vials?

Look-alike packaging can contribute to errors, and multiple-dose vials pose a risk for cross-contamination and over-dosing, highlighting the need for caution and proper labeling. Signup and view all the answers

What is the role of the 'five rights' of medication administration in preventing medication errors?

The 'five rights' of medication administration, including the right patient, right drug, right dose, right route, and right time, serve as a quick double check to be performed by healthcare professionals every time a medication is given, recommended to prevent medication errors. Signup and view all the answers

Explain the purpose of the 'five rights' in medication safety and why they need to be combined with other error prevention methods.

The 'five rights' in medication safety refer to the right patient, right drug, right dose, right route, and right time. While crucial, they need to be combined with other error prevention methods to provide a comprehensive approach to reducing medication errors. Signup and view all the answers

What is the role of barcoding in medication administration and how does it ensure the 'five rights'?

Barcoding in medication administration is a technological tool used to ensure the 'five rights' of medication administration. It helps by providing a method to accurately verify the medication, patient, and dosage, reducing the risk of errors. Signup and view all the answers

Why is monitoring for drug-food interactions crucial in medication safety?

Monitoring for drug-food interactions is crucial, especially for medications with high food interaction rates, as it helps to prevent adverse reactions and ensure the safe and effective use of medications. Signup and view all the answers

What is the significance of staff education programs in preventing medication errors?

Staff education programs, such as 'in-services', are essential for introducing new procedural changes and preventing medication errors by ensuring that healthcare professionals are knowledgeable about best practices and safety protocols. Signup and view all the answers

How do Computerized Prescriber Order Entry (CPOE) and Clinical Decision Support (CDS) tools contribute to reducing medication errors?

CPOE and CDS tools reduce errors and ambiguity in medical orders by providing a digital platform for accurate prescription entry and clinical decision support, which includes alerts for inappropriate drug orders or unsafe conditions. Signup and view all the answers

What is the FDA safety alert regarding the antidepressant citalopram, and why is it important in medication safety?

The FDA safety alert advises against using the antidepressant citalopram at doses greater than 40 mg/day due to potential heart abnormalities. This is important in medication safety to prevent adverse reactions and ensure patient well-being. Signup and view all the answers

How does barcode technology in medication administration contribute to accurate medication tracking and administration?

Barcode technology in medication administration automates charting, ensuring accurate medication tracking and administration, thereby reducing the risk of errors. Signup and view all the answers

What are the benefits of Automated Dispensing Cabinets (ADCs) in improving medication safety?

Automated Dispensing Cabinets (ADCs) automate drug inventory, improve controlled drug security, and provide usage reports, contributing to improved medication safety. Signup and view all the answers

Why is barcoding considered a critical tool in reducing medication errors?

Barcoding is a critical tool in reducing medication errors as it ensures proper drug stocking, compounding, and administration to the right patient by providing an accurate method of verification. Signup and view all the answers

How does barcode scanning enhance the safety of Automated Dispensing Cabinets (ADCs)?

Barcode scanning ensures the right drug is placed in the cabinet and administered to the right patient, enhancing ADC safety by reducing the risk of errors. Signup and view all the answers

What is the importance of combining Automated Dispensing Cabinets (ADCs) with barcoding in improving medication safety?

Automated Dispensing Cabinets (ADCs) provide alerts, usage reports, and work well with barcoding, improving medication safety by ensuring accurate drug tracking and administration. Signup and view all the answers

How do Computerized Prescriber Order Entry (CPOE) tools integrate clinical guidelines and patient labs to improve medication safety?

CPOE integrates clinical guidelines and patient labs, providing alerts for inappropriate drug orders or unsafe conditions, thereby contributing to improved medication safety. Signup and view all the answers

Explain the purpose of Medication Therapy Management (MTM) as mentioned in the text?

MTM aims to improve medication safety and management by targeting patients with multiple chronic conditions and high medication costs, using computer databases to identify high-risk patients and provide interventions. Signup and view all the answers

What is the recommended practice for handling Potassium Chloride (KCI) infusions according to the text?

Potassium Chloride (KCI) infusions should be prepared in the pharmacy and protocols for delivery should be used. Signup and view all the answers

What is the process of medication reconciliation as described in the text?

Medication reconciliation involves comparing a patient’s medication orders to all home medications to avoid errors, and is now usually performed within the electronic health record (EHR). It should be done at every transition of care, including hospital admission, transfer, and discharge. Signup and view all the answers

What is the significance of standardizing insulin infusions to one concentration?

Standardizing insulin infusions to one concentration makes it easier to use and manage. Signup and view all the answers

What is Medication Therapy Management (MTM) primarily focused on improving?

MTM primarily focuses on improving adherence, identifying cost-savings, and addressing missed therapies. Signup and view all the answers

What is the recommended practice regarding labeling of insulin according to the text?

Insulin should always be labeled with “units” or "units = mL" and avoid using "U" for units. Signup and view all the answers

What does Medication Therapy Management (MTM) include?

MTM includes comprehensive medication review and development of a medication-related action plan. Signup and view all the answers

What is the role of pharmacists in Medication Therapy Management (MTM) as mentioned in the text?

Pharmacists use computer databases to identify high-risk patients and provide interventions as part of MTM. Signup and view all the answers

What should be avoided when identifying medications based on, according to the text?

Avoid using "U" for units and always label with “units" or "units = mL" when identifying medications. Signup and view all the answers

What is the purpose of developing protocols for insulin infusions and transition to subcutaneous (SC) administration as mentioned in the text?

The purpose is to ensure safe and effective administration of insulin and to have clear guidelines for transition to subcutaneous administration. Signup and view all the answers

What is Medication Therapy Management (MTM) targeted at according to the text?

MTM targets patients with multiple chronic conditions and high medication costs to improve medication safety and management. Signup and view all the answers

What is the recommended practice for handling insulin in healthcare settings as mentioned in the text?

Insulin should not be placed in automated dispensing cabinets and all orders should be reviewed by a pharmacist. Signup and view all the answers

Explain the role of patient controlled analgesia (PCA) devices in managing post-surgical pain.

PCA devices allow patients to self-administer small doses of opioids for pain management, providing quick relief without the need to wait for a nurse. This method also helps in reducing side effects and can mimic the pain pattern more closely for effective pain control. Signup and view all the answers

What are some recommended strategies to reduce medication errors related to look-alike, sound-alike medications in Automated Dispensing Cabinets (ADCs)?

Storing look-alike, sound-alike medications in different locations within the ADC, using computerized alerts with pop-up alerts requiring confirmation, and avoiding certain medications like insulin, warfarin, and high-dose narcotics in ADCs are recommended strategies to reduce error risk. Signup and view all the answers

Why should nurses not be permitted to put medications back into the medication compartment in Automated Dispensing Cabinets (ADCs)?

Nurses should not be permitted to put medications back into the medication compartment to avoid placing them in the wrong area. It is best to have a separate drawer for all 'returned' medications. Signup and view all the answers

What are some considerations for using patient controlled analgesia (PCA) devices in busy or challenging environments?

In busy, noisy environments or those with poor lighting, errors in PCA administration may increase. It is important to consider the environmental factors and their impact on safe use of PCA devices. Signup and view all the answers

Which type of hand soap is preferred for reducing infections in healthcare facilities, and what are the environmental concerns associated with another effective hand soap?

Antimicrobial hand soaps with chlorhexidine (Hibiclens, others) are preferred. Triclosan is also effective but has environmental concerns due to its presence in the water supply. Signup and view all the answers

When should hand hygiene be performed in relation to patient contact and glove use?

Hand hygiene should be performed before and after patient contact, and before donning and after removing gloves. Signup and view all the answers

Why should oral solutions/suspensions never be administered intravenously?

Oral solutions/suspensions should never be administered intravenously to prevent fatal errors. Signup and view all the answers

In what situations is handwashing with soap and water necessary, and what should be used when caring for patients with diarrhea or known spore-forming organisms?

Handwashing with soap and water is necessary before eating, after using the restroom, and when visible soil is present on hands. Soap and water should be used when caring for patients with diarrhea or known spore-forming organisms. Signup and view all the answers

What are alcohol-based hand rubs not effective against, and what is the technique for handwashing with soap and water?

Alcohol-based hand rubs are not effective against spores. The technique for handwashing with soap and water involves wetting both sides of hands, applying soap, rubbing for at least 15 seconds, and thorough rinsing and drying. Signup and view all the answers

Why are safe injection practices crucial, and what should never be done with used needles or solution containers?

Safe injection practices are crucial to prevent the transmission of bloodborne pathogens and microbial pathogens to patients and healthcare workers. It is important never to reinsert used needles into a multiple-dose vial or solution container. Signup and view all the answers

What is essential for patients using injectable medications, and when is recapping a needle permitted?

Proper disposal of sharps is essential, and patients using injectable medications should have FDA-cleared sharps containers for immediate disposal after use. Recapping a needle is only permitted when a sharps container is not immediately available. Signup and view all the answers

Where can resources for guidelines and references on safe medication practices be found?

Resources for guidelines and references on safe medication practices include the Institute for Safe Medication Practices and The Joint Commission. Signup and view all the answers

What is the preferred soap for reducing infections in healthcare facilities?

Antimicrobial hand soaps with chlorhexidine (Hibiclens, others) are preferred. Signup and view all the answers

When is recapping a needle permitted?

Recapping a needle is only permitted when a sharps container is not immediately available. Signup and view all the answers

What should never be done with used needles or solution containers?

It is important never to reinsert used needles into a multiple-dose vial or solution container. Signup and view all the answers

What should be used when caring for patients with diarrhea or known spore-forming organisms?

Soap and water should be used when caring for patients with diarrhea or known spore-forming organisms. Signup and view all the answers

What are some risk factors for respiratory depression with Patient Controlled Analgesia (PCA)?

advanced age, obesity, and concurrent use of CNS depressants Signup and view all the answers

What are some common types of hospital-acquired infections mentioned in the text?

catheter-associated infections, bloodstream infections from IV lines, surgical site infections, and others Signup and view all the answers

What precautions are recommended for patients colonized or infected with MRSA, VRE, and C. difficile?

Contact precautions Signup and view all the answers

What are droplet precautions intended for, and when are they recommended?

to prevent transmission of pathogens spread through close respiratory contact; for specific diseases Signup and view all the answers

What are airborne precautions intended to prevent, and under what circumstances are they recommended?

to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air; for specific diseases Signup and view all the answers

What are some crucial strategies mentioned in the text to minimize catheter-related bloodstream infections?

aseptic technique during catheter insertion, minimizing catheter use, and hand hygiene Signup and view all the answers

What are some safety steps mentioned in the text for Patient Controlled Analgesia (PCA)?

limiting opioids in floor stock, using standard order sets, educating staff, and implementing protocols with independent double-checking and barcoding technology Signup and view all the answers

What is the significance of proper cleaning of surfaces in infection control?

It is crucial in infection control Signup and view all the answers

What are the two million infections occurring in hospitals annually causing, according to the text?

avoidable illness, death, and financial costs Signup and view all the answers

Who should administer Patient Controlled Analgesia (PCA) doses, according to TJC requirement?

well-coordinated healthcare teams; friends and family members should not administer PCA doses Signup and view all the answers

What is the recommended action before using Patient Controlled Analgesia (PCA) on patients?

Patients must be cooperative and undergo cognitive assessment before use Signup and view all the answers

What is the role of friends and family members in administering Patient Controlled Analgesia (PCA) doses, as per TJC requirement?

They should not administer PCA doses Signup and view all the answers

Study Notes

Organizations and Programs in Medication Safety and Quality Improvement

ISMP National Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program for medication errors.
Professionals and consumers are encouraged to report medication errors on the ISMP website, even if the error was reported internally.
When there are many reports of a particular error, the manufacturer may be required to take measures to increase safety.
Root Cause Analysis (RCA) is a retrospective investigation of an event that has occurred, used to design changes to prevent future errors.
Failure Mode and Effects Analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors.
The Joint Commission on Accreditation of Healthcare Organizations (TJC) accredits and certifies over 17,000 healthcare organizations and programs in the U.S.
TJC sets National Patient Safety Goals (NPSGs) annually for different healthcare settings, with defined measures called "Elements of Performance."
NPSGs include goals such as using at least two patient identifiers when providing care, treatment, and services.
NPSGs also include goals related to reporting critical results of tests and diagnostic procedures on a timely basis, and labeling all medications and containers.
NPSGs focus on reducing the likelihood of harm associated with anticoagulant therapy and maintaining accurate patient medication information.
NPSGs also focus on implementing evidence-based practices to reduce healthcare-associated infections, including multidrug-resistant organisms.
TJC conducts on-site surveys at least every three years for accredited organizations, with the possibility of unannounced surveys.

Organizations and Programs in Medication Safety and Quality Improvement

ISMP National Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program for medication errors.
Professionals and consumers are encouraged to report medication errors on the ISMP website, even if the error was reported internally.
When there are many reports of a particular error, the manufacturer may be required to take measures to increase safety.
Root Cause Analysis (RCA) is a retrospective investigation of an event that has occurred, used to design changes to prevent future errors.
Failure Mode and Effects Analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors.
The Joint Commission on Accreditation of Healthcare Organizations (TJC) accredits and certifies over 17,000 healthcare organizations and programs in the U.S.
TJC sets National Patient Safety Goals (NPSGs) annually for different healthcare settings, with defined measures called "Elements of Performance."
NPSGs include goals such as using at least two patient identifiers when providing care, treatment, and services.
NPSGs also include goals related to reporting critical results of tests and diagnostic procedures on a timely basis, and labeling all medications and containers.
NPSGs focus on reducing the likelihood of harm associated with anticoagulant therapy and maintaining accurate patient medication information.
NPSGs also focus on implementing evidence-based practices to reduce healthcare-associated infections, including multidrug-resistant organisms.
TJC conducts on-site surveys at least every three years for accredited organizations, with the possibility of unannounced surveys.

Medication Safety and Quality Improvement in Healthcare

A study by the Institute of Medicine (IOM) found that up to 98,000 Americans die each year in U.S. hospitals due to preventable medical errors, 7,000 from medication errors alone.
The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) are actively involved in improving medication safety.
Medication errors are defined as preventable events that may cause inappropriate medication use or patient harm, including errors in prescribing, order communication, labeling, dispensing, administration, education, and monitoring.
Sentinel events, unexpected occurrences involving death or serious injury, require investigation and measures to prevent recurrence.
Experts believe that system-based causes, rather than individual errors, are the most common cause of medication errors.
Errors of omission involve leaving out necessary information, while errors of commission involve doing something incorrectly, both compromising patient safety.
Medication errors, adverse drug reactions, hazardous conditions, and near misses should be reported to prevent similar errors in the future.
Institutions should have a plan in place for responding to medication errors, including internal and external notification, disclosure, investigation, and improvement.
Adverse drug reactions (ADRs) are different from medication errors and can occur as side effects from medication use.
Many state boards of pharmacy require quality assurance programs to prevent medication errors and mandate reporting errors to patients and prescribers.
Error investigations need to take place quickly, and many medication error reporting systems within hospitals are electronic.
Hospitals should inform their Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee of any errors.

Organizations and Programs in Medication Safety and Quality Improvement

ISMP National Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program for medication errors.
Professionals and consumers are encouraged to report medication errors on the ISMP website, even if the error was reported internally.
When there are many reports of a particular error, the manufacturer may be required to take measures to increase safety.
Root Cause Analysis (RCA) is a retrospective investigation of an event that has occurred, used to design changes to prevent future errors.
Failure Mode and Effects Analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors.
The Joint Commission on Accreditation of Healthcare Organizations (TJC) accredits and certifies over 17,000 healthcare organizations and programs in the U.S.
TJC sets National Patient Safety Goals (NPSGs) annually for different healthcare settings, with defined measures called "Elements of Performance."
NPSGs include goals such as using at least two patient identifiers when providing care, treatment, and services.
NPSGs also include goals related to reporting critical results of tests and diagnostic procedures on a timely basis, and labeling all medications and containers.
NPSGs focus on reducing the likelihood of harm associated with anticoagulant therapy and maintaining accurate patient medication information.
NPSGs also focus on implementing evidence-based practices to reduce healthcare-associated infections, including multidrug-resistant organisms.
TJC conducts on-site surveys at least every three years for accredited organizations, with the possibility of unannounced surveys.

Medication Safety and Error Prevention Methods

The "five rights" are a best practice in medication safety but must be combined with other error prevention methods.
Barcoding is a technological tool used in medication administration to ensure the "five rights."
Monitoring for drug-food interactions is crucial, especially with high-risk medications and enteral feedings.
Staff education programs, free from bias, are essential when introducing new high-alert drugs or procedural changes.
Computerized prescriber order entry (CPOE) reduces errors and clinical decision support (CDS) tools improve its effectiveness.
Citalopram should not be used at doses greater than 40 mg per day due to potential heart-related issues.
Barcode technology in medication administration automates the medication administration record, saving time.
Automated dispensing cabinets (ADCs) automate drug inventory, improve controlled drug security, and provide usage reports.
Barcoding is a crucial tool in medication error reduction, tracking the drug from the pharmacy to the patient.
ADCs provide alerts and work well with barcoding, and their use requires pharmacist review and oversight.
Barcoding ensures the right drug is stocked and administered to the right patient at the right time.
Barcode scanning improves ADC safety by ensuring the right drug is pulled and administered to the right patient.

Medication Safety and Error Prevention Methods

The "five rights" are a best practice in medication safety but must be combined with other error prevention methods.
Barcoding is a technological tool used in medication administration to ensure the "five rights."
Monitoring for drug-food interactions is crucial, especially with high-risk medications and enteral feedings.
Staff education programs, free from bias, are essential when introducing new high-alert drugs or procedural changes.
Computerized prescriber order entry (CPOE) reduces errors and clinical decision support (CDS) tools improve its effectiveness.
Citalopram should not be used at doses greater than 40 mg per day due to potential heart-related issues.
Barcode technology in medication administration automates the medication administration record, saving time.
Automated dispensing cabinets (ADCs) automate drug inventory, improve controlled drug security, and provide usage reports.
Barcoding is a crucial tool in medication error reduction, tracking the drug from the pharmacy to the patient.
ADCs provide alerts and work well with barcoding, and their use requires pharmacist review and oversight.
Barcoding ensures the right drug is stocked and administered to the right patient at the right time.
Barcode scanning improves ADC safety by ensuring the right drug is pulled and administered to the right patient.

Medication Safety Protocols in Hospitals

Insulin infusions will be standardized to one concentration
Protocols for insulin infusions, transition to SC, and sliding scale orders will be developed
Insulin should always be labeled with “units” or "units = mL", never just "mL"
Insulin should not be placed in automated dispensing cabinets
Medication Therapy Management (MTM) involves comprehensive medication review and development of a medication-related action plan
MTM targets patients with multiple chronic conditions and high medication costs
MTM initiatives aim to improve nonadherence and identify cost-savings
Potassium Chloride (KCI) infusions should be prepared in the pharmacy and have specific delivery protocols
Medication reconciliation involves comparing a patient’s medication orders to all of the medications the patient has been taking
It is now usually performed within the electronic health record (EHR)
Medication reconciliation should be done at every transition of care
Discharge medication reconciliation is an opportunity to address home medications and educate the patient

Patient Care and Infection Control in Hospitals

Patient Controlled Analgesia (PCA) devices are complex and require setup and programming, leading to preventable medication errors.
PCA treatment should be administered by well-coordinated healthcare teams to cooperative and cognitively assessed patients.
Friends and family members are not allowed to administer PCA doses, as per The Joint Commission requirement.
PCA usage does not frequently cause respiratory depression, but risk increases with advanced age, obesity, and concurrent use of CNS depressants.
Safety measures for PCAs include limiting opioids in floor stock, using standard order sets, and implementing protocols with independent double-checking and barcoding technology.
Hospital-acquired infections are a significant issue, with almost 2 million occurring annually, leading to avoidable illness, death, and financial costs.
States now require hospitals to report infection rates, and Medicare can refuse reimbursement for hospital-acquired infections.
Proper cleaning of surfaces, hand hygiene, and infection control measures are essential to prevent the spread of organisms like VRE, C. difficile, and noroviruses.
Common hospital-acquired infections include those from indwelling catheters, IV lines, surgical sites, decubitus ulcers, hepatitis, C. difficile, and pneumonia.
Infection control precautions include contact precautions for MRSA and VRE, droplet precautions for diseases like influenza, and airborne precautions for tuberculosis and varicella virus.
Minimizing catheter-related bloodstream infections involves aseptic technique during insertion, minimizing catheter use, and utilizing skin antiseptics and antibiotic impregnated central venous catheters.
Proper hand hygiene, including the use of alcohol-based hand rubs, is crucial in reducing the spread of nosocomial infections in healthcare settings.

Patient Care and Infection Control in Hospitals

Patient Controlled Analgesia (PCA) devices are complex and require setup and programming, leading to preventable medication errors.
PCA treatment should be administered by well-coordinated healthcare teams to cooperative and cognitively assessed patients.
Friends and family members are not allowed to administer PCA doses, as per The Joint Commission requirement.
PCA usage does not frequently cause respiratory depression, but risk increases with advanced age, obesity, and concurrent use of CNS depressants.
Safety measures for PCAs include limiting opioids in floor stock, using standard order sets, and implementing protocols with independent double-checking and barcoding technology.
Hospital-acquired infections are a significant issue, with almost 2 million occurring annually, leading to avoidable illness, death, and financial costs.
States now require hospitals to report infection rates, and Medicare can refuse reimbursement for hospital-acquired infections.
Proper cleaning of surfaces, hand hygiene, and infection control measures are essential to prevent the spread of organisms like VRE, C. difficile, and noroviruses.
Common hospital-acquired infections include those from indwelling catheters, IV lines, surgical sites, decubitus ulcers, hepatitis, C. difficile, and pneumonia.
Infection control precautions include contact precautions for MRSA and VRE, droplet precautions for diseases like influenza, and airborne precautions for tuberculosis and varicella virus.
Minimizing catheter-related bloodstream infections involves aseptic technique during insertion, minimizing catheter use, and utilizing skin antiseptics and antibiotic impregnated central venous catheters.
Proper hand hygiene, including the use of alcohol-based hand rubs, is crucial in reducing the spread of nosocomial infections in healthcare settings.

Hand Hygiene and Safe Injection Practices in Healthcare Facilities

Antimicrobial hand soaps with chlorhexidine (Hibiclens, others) are recommended for reducing infections in healthcare facilities.
Triclosan is effective but raises environmental concerns due to water supply contamination.
Hand hygiene is crucial before and after patient contact, donning and removing gloves, and handling invasive devices.
Oral solutions/suspensions should never be administered intravenously to avoid fatal errors.
Alcohol-based hand rubs are not effective in certain situations, such as when hands are visibly soiled or when caring for patients with certain infections.
Handwashing with soap and water physically removes spores and is recommended in specific cases.
Proper handwashing techniques and alcohol-based hand rub application are outlined for healthcare workers.
Unsafe injection practices can lead to outbreaks of blood-borne pathogens and other microbial infections.
Safety measures include using single-dose vials, engineered sharps protection, and proper disposal of needles and sharps.
Patients using injectable medications should have FDA-cleared sharps containers for proper disposal.
Recapping needles is only permitted when a sharps container is not immediately available, and specific one-hand methods are outlined.
Local trash removal services or health departments can provide information on sharps disposal guidelines and programs.

Organizations Specializing in Error Prevention

ISMP National Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program that analyzes system causes of medication errors and provides recommendations for prevention.
Medication errors and close calls can be reported on the ISMP website, even if they were reported internally.
When there are many reports of a particular error, the manufacturer may be required to take measures to increase safety.
Root cause analysis (RCA) is a retrospective investigation of an event to design changes that will prevent future errors.
Targeting corrective measures at the identified root cause is the best way to prevent similar problems from occurring in the future.
Failure mode and effects analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors.
NPSG 03.05.01 focuses on reducing the likelihood of harm associated with anticoagulant therapy.
NPSG 03.06.01 emphasizes maintaining and communicating accurate patient medication information.
The Joint Commission on Accreditation of Healthcare Organizations (TJC) accredits and certifies healthcare organizations, setting standards for quality and safety of care.
TJC sets annual National Patient Safety Goals (NPSGs) with defined measures for different healthcare settings.
NPSG 01.01.01 requires using at least two patient identifiers when providing care, treatment, and services.
NPSG 07.01.01 mandates compliance with the Centers for Disease Control (CDC) hand hygiene guidelines to reduce healthcare associated infections.

Medication Safety and Quality Improvement

The Institute of Medicine (IOM) study "To Err is Human" (1999) highlighted that up to 98,000 Americans die each year in U.S. hospitals due to preventable medical errors, with 7,000 from medication errors alone.
The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) are actively involved in improving medication safety in the U.S.
Medication errors are defined as preventable events causing inappropriate medication use or patient harm, encompassing prescribing, order communication, product labeling, dispensing, administration, and monitoring.
Sentinel events, involving death or serious injury, prompt investigation to prevent recurrence.
System-based causes, rather than individual errors, are identified as the most common cause of medication errors.
Errors of omission involve leaving out necessary safety measures, while errors of commission involve incorrect actions related to drugs or patients.
Reporting medication errors, adverse drug reactions, and hazardous conditions is crucial for preventing similar incidents in the future.
Institutions should have plans for internal notification, external reporting, disclosure, investigation, and improvement in response to medication errors.
Adverse drug reactions (ADRs) are distinct from medication errors and can occur without any error in prescribing or dispensing.
There are state board and ethical requirements for reporting and investigating medication errors, with some states mandating prompt reporting to patients and prescribers.
Many hospitals use electronic medication error reporting systems, while some still maintain paper-based systems.
The hospital's Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee should be informed of any medication errors.

Medication Safety and Management in Healthcare Settings

Standardize insulin infusions to one concentration for ease of use
Develop protocols for insulin infusions, transition to subcutaneous (SC) administration, and sliding scale orders
Avoid using "U" for units and always label with “units" or "units = mL"
Insulin should not be placed in automated dispensing cabinets and all orders should be reviewed by a pharmacist
Medication Therapy Management (MTM) includes comprehensive medication review and development of a medication-related action plan
MTM targets patients with multiple chronic conditions and high medication costs
Pharmacists use computer databases to identify high-risk patients and provide interventions
MTM initiatives focus on improving adherence, identifying cost-savings, and addressing missed therapies
Potassium Chloride (KCI) infusions should be prepared in the pharmacy and protocols for delivery should be used
Medication reconciliation involves comparing a patient’s medication orders to all home medications to avoid errors
Medication reconciliation is now usually performed within the electronic health record (EHR)
Medication reconciliation should be done at every transition of care, including hospital admission, transfer, and discharge

Hospital Safety Considerations

Patient Controlled Analgesia (PCA) devices are complex and require setup and programming, leading to preventable medication errors.
PCA should only be used by well-coordinated healthcare teams, and patients must be cooperative and undergo cognitive assessment before use.
Friends and family members should not administer PCA doses as per TJC requirement.
Risk of respiratory depression with PCA increases with advanced age, obesity, and concurrent use of CNS depressants.
Safety steps for PCA include limiting opioids in floor stock, using standard order sets, educating staff, and implementing protocols with independent double-checking and barcoding technology.
Nearly two million infections occur in hospitals annually, causing avoidable illness, death, and financial costs.
Proper cleaning of surfaces and preventing healthcare professionals from being sources of infection are crucial in infection control.
Common types of hospital-acquired infections include catheter-associated infections, bloodstream infections from IV lines, surgical site infections, and others.
Contact precautions are recommended for patients colonized or infected with MRSA, VRE, and C. difficile.
Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory contact and are recommended for specific diseases.
Airborne precautions are intended to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air.
Aseptic technique during catheter insertion, minimizing catheter use, and hand hygiene are crucial strategies to minimize catheter-related bloodstream infections.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Test your knowledge of medication safety and quality improvement programs and organizations with this quiz. Learn about the ISMP National Medication Errors Reporting Program, Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and the role of The Joint Commission on Accreditation of Healthcare Organizations (TJC) in setting National Patient Safety Goals (NPSGs) for healthcare settings.

Medication Safety and Quality Improvement Quiz

Choose a study mode

Podcast

Questions and Answers

What is a method to reduce medication errors mentioned in the text?

What is a practice for safe handling of emergency medications mentioned in the text?

What is recommended to avoid in identifying medications based on, according to the text?

What technology is mentioned for reducing medication errors in the text?

What is the definition of medication errors?

Who is involved in improving medication safety?

What are sentinel events?

What is believed to be the most common cause of medication errors?

What do errors of omission involve?

What should be reported to prevent similar errors in the future?

What should institutions have in place for responding to medication errors?

How are adverse drug reactions different from medication errors?

What do many state boards of pharmacy require to prevent medication errors?

What is the nature of medication error reporting systems within hospitals?

Who should hospitals inform of any errors?

What is the purpose of using tall man letters in drug names?

Why are abbreviations considered unsafe in the medical field?

What is the purpose of the TJC's 'Do Not Use' abbreviation list?

What is the recommended alternative for the abbreviation 'U' (unit)?

Why are high-alert drugs designated as such?

What is the purpose of using tall man lettering for high-alert drugs?

What is the purpose of drug dictionaries within computer systems and automated dispensing cabinets?

What is the issue with the abbreviation 'MS'?

Why are trailing zero (X.O mg) and lack of leading zero (X mg) problematic?

What is the recommended alternative for the abbreviation 'IU' (International Unit)?

Why is electronic prescribing preferred over handwritten prescriptions?

What is the purpose of limiting concentrations available in high-alert medications?

What is the purpose of the ISMP National Medication Errors Reporting Program (MERP)?

What is the purpose of Root Cause Analysis (RCA)?

What does Failure Mode and Effects Analysis (FMEA) aim to do?

What is the role of The Joint Commission on Accreditation of Healthcare Organizations (TJC)?

What are National Patient Safety Goals (NPSGs) focused on?

What is the frequency of on-site surveys conducted by TJC for accredited organizations?

What is the purpose of ISMP National Medication Errors Reporting Program (MERP)?

What is the focus of NPSGs regarding patient care, treatment, and services?

What are professionals and consumers encouraged to do regarding medication errors?

What is the role of the manufacturer when there are many reports of a particular error?

What is the focus of NPSGs regarding diagnostic procedures?

What is the purpose of Failure Mode and Effects Analysis (FMEA)?

Is the use of 'Do Not Use' abbreviations recommended to reduce medication errors?

Is medication reconciliation mentioned as a method to reduce medication errors?

Is the use of the metric system recommended to identify medications based on packaging alone?

Is hand hygiene mentioned as a method to prevent transmission of infections in hospitals?

Is the use of tall man letters recommended to reduce confusion between similar drug names?

Is the use of abbreviations considered safe in the medical field?

Is electronic prescribing mentioned as a method to reduce errors associated with poor handwriting?

Is handwritten prescriptions and progress notes no longer used in many settings?

Are high-alert drugs with a heightened risk of causing significant patient harm designated as such?

Are look-alike, sound-alike medications a common cause of medication errors?

Are poor handwriting and similar product labeling mentioned to aggravate the problem of medication errors?

Is the lack of leading zero (X mg) considered problematic?

Are high-alert medications recommended to be used safely by developing protocols or order sets for use?

Are trailing zero (X.O mg) and lack of leading zero (X mg) considered problematic?

Is the purpose of using tall man letters for high-alert drugs mentioned in the text?

Is the purpose of using tall man letters in drug names mentioned to reduce confusion between similar drug names?

Root Cause Analysis (RCA) is a proactive investigation of an event that has occurred, used to design changes to prevent future errors.

Failure Mode and Effects Analysis (FMEA) is a retrospective method used to reduce the frequency and consequences of errors.

The Joint Commission on Accreditation of Healthcare Organizations (TJC) accredits and certifies over 20,000 healthcare organizations and programs in the U.S.

NPSGs include goals related to reporting critical results of tests and diagnostic procedures on a timely basis, and labeling all medications and containers.

NPSGs focus on reducing the likelihood of harm associated with anticoagulant therapy and maintaining accurate patient medication information.

TJC conducts on-site surveys at least every four years for accredited organizations, with the possibility of unannounced surveys.

ISMP National Medication Errors Reporting Program (MERP) is an anonymous national voluntary reporting program for medication errors.

Professionals and consumers are discouraged from reporting medication errors on the ISMP website if the error was reported internally.

When there are many reports of a particular error, the manufacturer may not be required to take measures to increase safety.

FMEA is a proactive method used to increase the frequency and consequences of errors.

RCA is a retrospective investigation of an event that has occurred, used to design changes to prevent future errors.

MERP is a confidential national voluntary reporting program for medication errors.

Sentinel events require investigation and measures to prevent recurrence.

Errors of omission involve leaving out necessary information, while errors of commission involve doing something correctly.

Adverse drug reactions (ADRs) are the same as medication errors.

Many state boards of pharmacy require quality assurance programs to prevent medication errors and mandate reporting errors to patients and prescribers.

Error investigations need to take place quickly, and many medication error reporting systems within hospitals are paper-based.

Hospitals should inform their Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee of any errors.

The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) are not actively involved in improving medication safety.

Experts believe that individual errors are the most common cause of medication errors.

Medication errors, adverse drug reactions, hazardous conditions, and near misses should not be reported to prevent similar errors in the future.