Medication Safety

Multi-Use Insulin Process

• Insulin vials are added to Omnicell as "standard stock."
• Nurses follow a protocol to prepare insulin doses, label syringes, and administer medication.
• Two RNs must check and sign off on the process in LifeChart before administration.
• Insulin vials are returned to Omnicell after use to ensure proper inventory management.

Failure Mode and Effects Analysis (FMEA)

• FMEA identifies potential failure modes in processes and assesses their impact.
• Risk Priority Number (RPN) categories indicate severity levels of process failures:
  • 400 or higher: Critical failures with minimal current safeguards.
  • 300-399: Significant failures with some mitigation strategies.
  • 100-299: Moderate failures with multiple controls in effect.
  • Less than 100: Minimal risk failures, suggesting robust safeguards.

Root Causes of Failure

• A team-based approach is vital for conducting root cause analysis.
• Utilizing the "5 Whys" technique helps to delve deeper into underlying issues.
• Documenting specific causes of failures allows for targeted action plans.
• Developing thorough workflows using flowcharting can streamline processes for better safety.

Interruptions and Medication Errors

• Interruptions during medication preparation can lead to a ~12% increase in errors.
• Strategies to reduce distractions include defining critical tasks and establishing "no interruption zones."
• Minimizing unnecessary alarms and alerts can facilitate a more focused work environment.

Emerging Threats to Safe Medication Systems

• The pandemic led to increased medication errors due to disrupted learning and training opportunities.
• Ongoing workforce crises result in burnout, anxiety, and insufficient trainers.
• Challenges like retroactive charting and use of proxy scanning underscore the need for vigilance.

Key Event and Safety Culture

• A case involving a 66-year-old discharged patient highlights the importance of standardized workflows to minimize variations.
• Organizations should acknowledge potential failures proactively and learn from near misses rather than becoming complacent.
• Promoting internal reporting of medication errors enhances organizational safety culture.

Swiss Cheese Model of Error Causation

• This model illustrates how system safeguards can have weaknesses ("holes"), leading to potential failures.
• Characteristics of High Reliability Organizations (HRO) can help identify opportunities for improvement.
• Concepts of Just Culture emphasize the need for a supportive environment to encourage error reporting without blame.

Medication Safety Closed Loop

• Successful medication safety involves multiple integrated systems across prescribing, administration, and charting.
• Clinical decision support and barcode scanning technology enhance effective medication administration.
• High-reliability practices include ensuring the "Right Patient,” “Right Drug,” “Right Time,” and “Right Dose” during medication delivery.

Swiss Cheese Holes and Distractions

• Likelihood of medication errors increases significantly due to frequent distractions, averaging every 2 minutes in healthcare settings.
• Addressing look-alike/sound-alike medication issues is critical for patient safety in medication administration.

This quiz covers the procedures involved in the multi-use insulin process, including protocol for preparation and administration by nurses. It also delves into Failure Mode and Effects Analysis (FMEA), highlighting risk categories and root cause analysis techniques such as the '5 Whys'.