Medication Use Process and Errors Quiz

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Questions and Answers

What was the initially signed dosage of methotrexate according to the drug chart?

100 mg daily (correct)

50 mg daily

200 mg daily

10 mg daily

What did the doctor rely on to verify the correct methotrexate dosage?

The patient's report

The pharmacy's input

Confirmation from non-medical staff (correct)

Blood count results

What was the cause of death recorded on the patient's death certificate?

Stroke

Cardiac arrest

Gastrointestinal hemorrhage and pancytopenia (correct)

Pulmonary embolism

During which stage do medication errors occur most frequently?

Prescribing Signup and view all the answers

What percentage of medication errors is attributed to the administration stage?

26%-38% Signup and view all the answers

What is the primary cause of most medication errors?

Poor prescribing skills Signup and view all the answers

What is a key strategy for reducing medication errors?

Developing a supportive safety culture Signup and view all the answers

How many sections are included in the Prescribing Safety Assessment (PSA)?

8 Signup and view all the answers

According to the content, what is essential for improving the rate of reporting medication errors?

A supportive safety culture Signup and view all the answers

What does the phrase 'To err is human, to cover up is unforgivable but to fail to learn is inexcusable' imply?

Learning from mistakes is a critical part of patient safety. Signup and view all the answers

What are the key components of the medicines use process?

Transcribing, dispensing, monitoring, and prescribing Signup and view all the answers

What was the overall error rate for medication orders in the EQUIP study?

8.9% Signup and view all the answers

Which group of doctors had a slightly lower error rate for prescriptions according to the EQUIP study?

Year 1 doctors Signup and view all the answers

Who is primarily responsible for administering medications in a hospital setting?

Nurses Signup and view all the answers

What was the outcome of the prescribing error in The Cambridgeshire Enquiry?

The patient experienced adverse reactions due to medication errors. Signup and view all the answers

What percentage of potentially lethal errors were found in prescriptions?

Under 2% Signup and view all the answers

Which professionals are involved in the transcribing phase of the medication-use process?

Doctors, pharmacists, and nurses Signup and view all the answers

What is one example of a prescribing error mentioned?

Neglecting dose adjustments for kidney function Signup and view all the answers

What role do pharmacists play in the context of prescribing errors?

They intercept almost all errors before affecting patient care. Signup and view all the answers

What is a common thread among all team members involved in medication safety?

They all play a crucial role in ensuring safe medication use. Signup and view all the answers

Which group is NOT primarily involved in the dispensing phase of the medication-use process?

Doctors Signup and view all the answers

Which of the following is NOT a recommended practice for risk management in prescribing?

Ignoring patient concerns regarding medications Signup and view all the answers

What error did the GP make during the prescribing process in The Cambridgeshire Enquiry?

Prescribing a lower dosage for daily intake. Signup and view all the answers

What kind of errors can occur with electronic prescribing?

Incorrect medication or wrong strength Signup and view all the answers

What is a common cause of prescribing errors related to handwriting?

Illegible handwriting in prescriptions Signup and view all the answers

What should healthcare professionals appreciate about using medicines safely?

It involves complex skills that require teamwork. Signup and view all the answers

What should pharmacies avoid in order to reduce SALAD errors?

Stocking medication with packaging prone to SALAD errors Signup and view all the answers

Which of the following is NOT one of the myths of human error according to James Reason?

Errors are an essential part of learning Signup and view all the answers

According to Reason's model, what contributes to error-producing conditions?

Environmental, team, individual, or task factors Signup and view all the answers

What was the cause of the vincristine medication error reported?

Administration route was unclear Signup and view all the answers

What approach does aviation take towards errors compared to healthcare?

Expect things to go wrong and design systems to compensate Signup and view all the answers

Which aspect of human error does James Reason emphasize in his work?

System design plays a crucial role in errors Signup and view all the answers

What outcome is deemed rare among highly trained professionals according to common misconceptions?

Errors affecting patient safety Signup and view all the answers

What is a latent condition in the context of accident causation models?

Underlying organizational problems Signup and view all the answers

What was the primary error made by the nurse in the case of the patient who received naloxone?

Mishearing the drug name due to a similar sound Signup and view all the answers

Which strategy is recommended to reduce SALAD errors in prescribing medications?

Specify the exact dose on the prescription Signup and view all the answers

What was the effect of administering amiodarone instead of amantadine?

The patient suffered from worsened dyskinesia Signup and view all the answers

How can healthcare professionals minimize the risk of errors related to drug names?

Writing full drug names instead of abbreviations Signup and view all the answers

What additional information should be included on a prescription to enhance clarity?

Indications for the medication Signup and view all the answers

What percentage range of medication errors occur during the prescribing stage?

39%–49% Signup and view all the answers

Which of the following contributed to the misadministration of methotrexate in The Cambridgeshire Enquiry?

Confusion from a non-medical staff member's confirmation Signup and view all the answers

What is the percentage of medication errors attributed to the administration stage?

26%–38% Signup and view all the answers

In The Cambridgeshire Enquiry, what was the ultimate outcome faced by the patient as a result of the medication error?

Deterioration leading to death Signup and view all the answers

Which phase of the medication-use process had the least percentage occurrence of errors according to the data presented?

Transcribing Signup and view all the answers

What is a primary factor contributing to medication errors according to the conclusions?

Poor prescribing practices Signup and view all the answers

Which component of the Prescribing Safety Assessment (PSA) is focused on patient engagement?

Providing Information Signup and view all the answers

What is suggested as a means to improve the reporting rates of medication errors?

Adopting a supportive safety culture Signup and view all the answers

Which quote reflects the importance of learning from errors in healthcare?

To err is human, but to fail to learn is inexcusable. Signup and view all the answers

How can the multifactorial nature of medication errors be best summarized?

Sources and methods of errors are diverse and require collaboration. Signup and view all the answers

What is one of the components of the medicines use process?

Administering medications Signup and view all the answers

Which healthcare professional is primarily responsible for monitoring medication therapy?

Pharmacists Signup and view all the answers

What type of error was made by the GP in The Cambridgeshire Enquiry?

Incorrect dosage form prescribed Signup and view all the answers

Which of the following best describes the role of pharmacists in the medication-use process?

Endorsing prescriptions with administration directions Signup and view all the answers

Which stage is involved in the transcribing aspect of the medication-use process?

Transcribing drug orders to pharmacy Signup and view all the answers

What is a critical aspect emphasized for safe medication use?

It is a team effort involving multiple healthcare professionals Signup and view all the answers

What was the outcome of the prescribing error in The Cambridgeshire Enquiry?

The patient was admitted to the hospital Signup and view all the answers

Which professional is NOT primarily involved in the dispensing phase of the medication-use process?

Doctors Signup and view all the answers

What was the error rate reported for medication orders in the EQUIP study?

8.9% Signup and view all the answers

Which of the following is a common example of a prescribing error?

Neglecting dose adjustments for kidney function Signup and view all the answers

In which situation is a prescribing error least likely to occur?

For prescriptions verified by a pharmacist Signup and view all the answers

What percentage of prescriptions contained potentially lethal errors according to the findings?

2% Signup and view all the answers

Which of the following strategies is NOT recommended for risk management in prescribing?

Ignoring patient's concerns Signup and view all the answers

What is the role of pharmacists in the context of prescribing errors?

To intercept errors before they affect patient care Signup and view all the answers

Which group of doctors exhibited an error rate for prescriptions that was slightly lower than the overall study rate?

Year 2 doctors Signup and view all the answers

What approach should be taken when selecting the most appropriate medicine?

Use resources like the BNF and clinical guidelines Signup and view all the answers

What action did the nurse take upon discovering the incorrect dosage of methotrexate on the drug chart?

Confirmed the accuracy of the dosage with the patient. Signup and view all the answers

What was identified as a potential cause of the patient's deteriorating condition?

Administration of methotrexate. Signup and view all the answers

What is the most critical error identified in the scenario concerning methotrexate dosage?

Reliance on a non-medical staff member for drug dosage confirmation. Signup and view all the answers

In the medication error statistics presented, which stage accounted for the second-highest percentage of errors?

Administration stage. Signup and view all the answers

What documented consequence resulted from the medication error involving methotrexate?

Gastrointestinal haemorrhage and subsequent death. Signup and view all the answers

What was the primary reason for the patient's death in the case involving naloxone and Lanoxin?

The nurse mistakenly administered the wrong medication. Signup and view all the answers

Which of the following strategies is recommended to effectively reduce SALAD errors?

Utilize 'tall man' lettering for high-alert medications. Signup and view all the answers

What specific prescribing practice is recommended to increase clarity and decrease errors?

Writing the full drug name and dosage clearly. Signup and view all the answers

What was the consequence of administering amiodarone instead of amantadine for the Parkinson's patient?

Dyskinesia dramatically improved after stopping amiodarone. Signup and view all the answers

Which practice could help to address the issue of similar-sounding drug names during medication administration?

Enhancing visual identification methods and labeling. Signup and view all the answers

What role does the community pharmacist play in the medication-use process during the prescribing phase?

Amending preadmission medications Signup and view all the answers

In The Cambridgeshire Enquiry, what was the consequence of the GP incorrectly prescribing methotrexate?

The patient ended up hospitalized due to the error Signup and view all the answers

Which group of healthcare professionals is NOT involved in the administering phase of the medication-use process?

Dieticians Signup and view all the answers

What aspect of medicine safety does the content emphasize regarding team involvement?

Everyone on the team plays a role in safely using medicines Signup and view all the answers

According to the presented content, what is a key component of the medicines use process that is critical for error reduction?

Clear communication among professionals Signup and view all the answers

In which phase of the medication-use process would a GP likely identify the error made by the locum pharmacist?

Monitoring phase Signup and view all the answers

What is a significant challenge highlighted in the medication-use process concerning complex prescriptions?

Preventing digital errors in computerized systems Signup and view all the answers

Which strategy is emphasized as effective in improving the safety and accuracy of the medication-use process?

Regular training and interprofessional collaboration Signup and view all the answers

What is a significant outcome of adopting a supportive safety culture in healthcare?

Higher rates of reporting medication errors Signup and view all the answers

Which statement best reflects the complexity of medication errors?

The sources of medication errors are diverse and require multidisciplinary approaches. Signup and view all the answers

According to the conclusions discussed, what is the primary reason for varying rates of medication errors?

Diverse definitions and methodologies in error reporting Signup and view all the answers

Which element is NOT a component of the Prescribing Safety Assessment (PSA)?

Pharmacokinetics Overview Signup and view all the answers

What is the main focus of improving prescribing skills in relation to medication errors?

To address the root causes of medication errors effectively Signup and view all the answers

What is one of the significant factors that contributed to the error in Mrs. Moira Pullar's case?

Poor handwriting led to misinterpretation of the dosage Signup and view all the answers

What best practice should be followed when writing dosages to avoid misinterpretation?

Always precede decimal points with a zero Signup and view all the answers

Which abbreviation has the potential to be mistaken for the number 10?

IU Signup and view all the answers

In the context of error-prone abbreviations, what is the best expression for milliliters?

mL Signup and view all the answers

What common error can occur with the representation of the unit 'U'?

Mistaken as a full unit of volume Signup and view all the answers

Which practice is NOT recommended to minimize the risk of medication errors?

Employing numerous abbreviations Signup and view all the answers

What is recommended to do with quantities of less than 1 gram?

Express them in milligrams Signup and view all the answers

Which of the following best illustrates the concept of 'sound-alike look-alike' drug errors?

Drugs with similar names causing confusion, like aminophylline and amitriptyline Signup and view all the answers

To ensure patient safety, what should be done when leading zeros are not present?

Always precede essential decimal points with a zero Signup and view all the answers

What type of errors does the abbreviation 'ng' typically lead to when misinterpreted?

Overdosage due to being mistaken as nasogastric Signup and view all the answers

Study Notes

Medication Use Process

The medication use process involves various stages: prescribing, transcribing, dispensing, administering, and monitoring.
In a hospital setting, different healthcare professionals are involved at each stage.
Doctors, pharmacists, nurses, and dieticians play crucial roles.

Prescribing Competency Framework

The Cambridgeshire Enquiry highlighted a medication error involving methotrexate, leading to a patient's death.
The incident revealed a series of failures across multiple stages of the medication use process.
The inquiry emphasized the importance of robust prescribing practices and multidisciplinary collaboration.

Medication Error

A medication error is defined as a preventable event that can lead to inappropriate medication use or harm to the patient.
Studies indicate medication errors are most common during prescribing and administration, followed by transcribing and dispensing.
The majority of errors occur during the prescribing stage, emphasizing the need for improved skills.

Prescribing Errors

Common prescribing errors include incorrect dosing, drug interactions, illegible handwriting, and electronic prescribing errors.

Risk Management - Prescribing the Right Medicine

Taking a comprehensive drug history is crucial to prevent errors, including prescription and over-the-counter medications, herbal remedies, and illicit drugs.
Choosing the most appropriate medication involves utilizing resources like the BNF and guidelines, and seeking expert advice.

SALAD Errors

SALAD errors stand for sound-alike/look-alike drugs, increasing the risk of medication errors.
Pharmacies should avoid stocking medication with packaging prone to such errors, implementing a "purchase for safety policy."

Reason's Model of Accident Causation

James Reason's model explains that accidents are often the result of a complex interaction of latent conditions and active failures.
Latent conditions refer to underlying organizational processes, management decisions, and environmental factors.
Active failures are errors or violations committed by individuals during the course of their work.

Vincristine Medication Error Case Report

A tragic case involved the administration of vincristine intrathecally instead of intravenously, resulting in the patient's death.
The incident highlights the importance of clear communication, familiar protocols, and robust safety checks to prevent such errors.
The latent failure model can be modified from the original model to illustrate and analyze such medication errors.

Error Reduction Strategies

Effective communication, collaboration, and shared learning are crucial for reducing medication errors.
Strategies include implementing prescribing safety assessments (PSAs), utilizing drug information resources, and empowering patients to participate in their medication management.

Patient Empowerment for Medication Safety

Patients are actively encouraged to engage in their medication safety by:
Informing their healthcare providers about their complete medication history.
Understanding their medications and potential risks.
Reporting any concerns or adverse events.

Conclusions

Medication errors are commonly preventable, and addressing them is paramount to patient safety.
A supportive safety culture must be cultivated to encourage reporting medication errors and facilitate further investigation.
Improving prescribing competency, communication, and collaboration is essential to minimize preventable harm.

Medication-Use Process

The medication-use process includes prescribing, transcribing, dispensing, administering, and monitoring.
Each stage involves multiple healthcare professionals, including doctors, pharmacists, nurses, and dieticians.

Prescribing Competency Framework

The prescribing competency framework guides healthcare professionals in the safe and effective prescribing of medicines.

The Cambridgeshire Enquiry

A woman with rheumatoid arthritis was prescribed methotrexate by her consultant, with her GP responsible for adjusting the dose.
A series of prescribing errors occurred throughout the process, resulting in an incorrect dose being administered and contributing to the patient's death.

Medication Error

A medication error is any preventable event that leads to inappropriate medication use or harm to the patient.
Errors commonly occur during prescribing and administering medication, but they can also occur during transcribing and dispensing.

Prescribing Errors

Common Examples:
- Incorrect dosing.
- Drug interactions with other medications.
- Illegible handwriting on prescriptions.
- Electronic prescribing errors.

Risk Management - The Right Medication

It is essential to take a full drug history from patients.
This includes current prescriptions, non-prescription medications, herbal remedies, illicit drugs, and any adverse drug reactions (ADRs) or allergies.
Choose the most appropriate medication, using resources like the British National Formulary (BNF) and relevant guidelines.

Risk Management - Legibility

Handwritten prescriptions can lead to errors due to illegible handwriting.
Use clear, complete drug names to avoid confusion.
Specific doses should always be written, avoiding generic terms like "as directed."

Risk Management - Abbreviations

Never abbreviate medication names.
Abbreviations can lead to confusion and misinterpretation.
Ensure clear communication and accurate dispensing of medication.

Error Reduction Strategies

Prescribing Safety Assessment (PSA):
- A 120-minute assessment tool with eight sections covering aspects of prescribing safety, including drug monitoring, adverse drug reactions, and patient empowerment.

Patient Empowerment for Medication Safety

Patients should be actively involved in their medication safety by:
- Understanding the risks and benefits of their medicines.
- Reporting any concerns or adverse effects promptly.
- Taking an active role in managing their medication use.

Conclusions

Medication errors are a preventable cause of patient injury.
Most medication errors occur due to inadequate prescribing practices.
A supportive safety culture is crucial to improve reporting and address the causes of preventable harm.

Patient Safety and Medicines

Key quote: "To err is human, to cover up is unforgivable but to fail to learn is inexcusable." (Sir Liam Donaldson, World Health Organisation, 2004).
Continuous learning and improvement are essential for medication safety.

Medication Use Process

The medication use process involves prescribing, transcribing, dispensing, administering, and monitoring
In a hospital setting, the process involves doctors, pharmacists, nurses, and sometimes dieticians
There are specific roles for each of those professions at each step of the process

Prescribing Competency Framework

The Cambridgeshire Enquiry is a real-life example of how medication errors can occur
The enquiry highlighted a series of mistakes resulting in a patient's death due to a medication error
The mistakes involved misinterpretations, poor communication, system failures, and lack of follow-up

Medication Error

A medication error is an event that could cause or lead to inappropriate medication use or patient harm
They can occur at any stage of the medication use process
Studies suggest prescribing and administration stages have the highest occurrences of medication errors

Case Study: Mrs. Moira Pullar

Mrs. Pullar died after being administered ten times too much insulin due to a medication error
The error involved poor handwriting by the prescriber, failure of nurses and doctors to check the dosage and monitor the patient, and unclear prescription charting
The case highlights the importance of clear and accurate record-keeping and the need for robust safety measures to prevent such tragedies

Risk Management: Abbreviations

Abbreviations should be avoided as they can be misinterpreted, potentially leading to errors
Examples include "IU" (International Unit) mistaken for IV (intravenous) or "l" (liter) mistaken for the number 1
It is recommended to use full terms and avoid unnecessary decimal points, especially trailing zeros

Dispensing & Administration Errors

Dispensing and administration errors can occur due to sound-alike and look-alike drugs (SALADS)
These errors can be mitigated by using the full drug name on prescriptions and labels
"Tall man" lettering can be used to highlight key differences in SALAD names

Risk Management: Numerals

Using numerals can reduce medication errors as they are less prone to misinterpretation
For example, writing "2mg" instead of "two mg" can prevent confusion

Error Reduction Strategies

Strategies to reduce medication errors include using prescribing safety assessments (PSA), patient empowerment, and fostering a culture of safety
PSA involves a structured approach to prescribing, including review, planning, management, and patient information
Patient empowerment fosters a supportive environment where patients actively participate in their medication management

Patient Empowerment for Medication Safety

Patients play a crucial role in medication safety
They should be encouraged to ask questions, understand their medications, and report any concerns
Empowering patients strengthens their role in medication safety and improves overall outcomes

Conclusions

Medication errors are a preventable cause of patient harm
Errors are often rooted in poor prescribing practices, highlighting the need for improved prescribing skills
A multidisciplinary approach to medication safety and a supportive safety culture are essential to reduce medication errors and learn from them

Patient Safety and Medicines

Preventing medication errors requires a commitment to continuous learning and improvement
Fostering a culture of openness and accountability is essential for reporting and learning from medication errors
"To err is human, to cover up is unforgivable but to fail to learn is inexcusable." - Sir Liam Donaldson, World Health Organisation (2004)

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Description

Test your knowledge on the medication use process, including stages like prescribing and administering. Explore the roles of healthcare professionals and the impact of medication errors highlighted by significant inquiries. Understand the importance of robust practices and collaborative efforts in preventing such errors.