Definitions
Define ‘adverse drug event’
Harm or injury experienced by a patient resulting from exposure to a medication
What is the potential problem with the following prescription:
Smith, Sam DOB: 2/15/72
Rosuvastatin 5mg Q.O.D. for cholesterol
#12 for 28 day supply; 6 refills
Dr. Frees
Q.O.D. mistaken for QID
Write ’every other day’
List 3 examples of ISMP’s risk reduction strategies for medication errors
Do not use list
List of confused Drug Names
TALLman Lettering Technique
Is the following a medication error or adverse drug event? A pharmacist accidently fills a prescription written ‘torsemide 10mg BID’ as ‘torsemide 100mg BID’. The patient ends up requiring a hospitalization for acute kidney injury.
Medication error and adverse drug event
Define ’medication error’
Any mistake in the medication process, regardless of the outcome
What is the potential problem for the abbreviation ‘MgSO4’ and what should be used instead?
Mistaken for morphine sulfate
Write ‘magnesium sulfate’ or vice versa
List 4 technological strategies to reduce medication errors
Computerized physician order entry
Automated drug-distribution cabinets enabled with bar-code scanning
Bar-code-assisted medication administration (BCMA)
Smart IV infusion pumps with a two-way interface to an electronic medical record (EMR)
Is the following a medication error or adverse drug event? A 1-year-old patient with no known previous drug allergies has an anaphylactic reaction to penicillin.
Adverse drug event
Define ‘medication reconciliation’
Process of obtaining most accurate patient medication list including drug name, dose, frequency and route
Describe how to properly document numbers with decimal points
Do not use trailing zero (4.0 --> 4)
Do no omit leading zero (.4 --> 0.4)
List 3 communication medication error risk reduction strategies
1. Spell sound-alike drug names back to caller and obtain indication for use from caller for sound-alike medications
2. Read back when accepting prescription spoke prescription orders to confirm understanding
3. Repeat numbers in digits when receiving oral prescription orders (16 is stated “one-six”, 60 is stated “six-zero”)
4. Call prescribers when prescriptions need clarification
5. Never use error-prone abbreviations or medication abbreviations
Is the following a medication error or adverse drug event? The nighttime nurse called in sick and did not show up for work. Meanwhile, the daytime nurse left 10 minutes early. The patient missed her 8pm medication dose of lisinopril and her blood pressure was elevated the following morning.
Medication error
Define ‘Just Culture’
Concept for health care systems where errors lead to system changes rather than punishment
Which of the following abbreviations is on The Joint Commission ‘potential do not use list’
A.IU
B. U
C. cc
D. QD
C. cc
True/False
Smart pumps prevent nursing staff from administering medication from outside the pre-specified range
False: some stops may be overridden
Is the following a medication error or adverse drug event?
A 42 year old patient with severe hepatic disease was given an IM dose of ziprasidone for agitation. Ziprasidone is metabolized in the liver and causes QTc prolongation. The patient was exposed to too much medication as he was not able to properly metabolize it. This resulted in a fatal arrhythmia and death.
Adverse drug event and medication error
Define 'confirmation bias'
Individuals select what they expect to see rather what is actually there
Can you read this Rx?
Multivitamin, #30, 1 tablet po qd.
What analysis can be conducted to analyze the potential for error/failure?
Failure mode and effects analysis (FMEA) is a process to systematically identify areas of potential failure within a process and gauge what the effects would be—before an error actually takes place
As a pharmacy student intern, list two ways (or actions you will take) to incorporate medication safety into your practice
Ask Questions
Double Check Work
Call providers/prescribers to verify
Provide counseling - inform patient
Double check names when dispensing
Etc.