Terms
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
What is an error?
Any preventable event that may cause or lead to inappropriate medication use or patient harm
What is a medication error?
The founder of the “Swiss cheese model”
Who is James Reason?
This harm score category describes circumstances or events that have the capacity to cause error.
What is category A or unsafe conditions?
An unexpected occurrence involving death or serious physical or psychological injury or “risk thereof.”
What is a sentinel event?
Freedom from accidental injury
The establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them so that harm won’t occur
What is patient safety?
Any response that is noxious, unintended, and undesired occurring at doses normally used in man for prophylaxis, diagnosis, or therapy
What is an adverse drug reaction?
This man, sometimes known as the “father of patient safety,” defined medical error.
Who is Lucian Leape?
This harm score category is an error occurred that may have contributed or resulted in patient death
What is category I?
Failure to see an object because attention is not focused on it
What is inattentional blindness?
The broad term applied to both ADE’s and medication errors
What are medication misadventures?
Describes any harm resulting from the use of a medication
What is an adverse drug event?
This organization defined "sentinel event."
Who is The Joint Commission?
This is a type of human error, an attention failure
What is a slip?
You see what you want to see.
You hear what you want to hear.
What is confirmation bias?
Developed by James Reason to describe how an error happens with active and latent failures
What is the Swiss cheese model?
Errors that have the potential to cause patient harm but did not
What are near-misses or close calls?
In 2009, this group finalized the definition for near misses.
Who is is NCC-MERP?
This describes human error that occurred at a conscious level
What is a mistake?
Working around safety standards becoming the norm over time
What is normalization of deviance?
Two types of failures that allow an error to propagate through a system/process
What are active or latent failures?
Drugs that bear a heightened risk of causing significant patient harm when they are used in error
What are high alert medications?
This group developed the taxonomy for medication error harm scores.
Who is is NCC-MERP?
A type of human error, this is a memory failure
What is a lapse?
These are two drug classes that are considered high alert medications
What are opioid infusions, chemotherapy, anticoagulants, insulin, concentrated electrolytes, neuromuscular blocking agents?