Lecture 16: A Culture of Patient Safety Flashcards Preview

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ISMP (Canada) The Institute for Safe Medication Practices Canada
Canadian Patient Safety Institute

what does it do?

The Institute for Safe Medication Practices Canada is an independent national not‐for‐profit organization committed to the advancement of medication safety
in all healthcare settings.
promote safe med practices

CPSI works with gov't and organizations to improve pt safety and quality


which book breaks the silence that has surrounded medical errors and their consequences by not pointing fingers at individuals sets forth a national agenda for reducing medical errors and improving patient safety through the design of a safer health system

To Err is Human


Define culture of patient safety

A safety culture exists within an organization [when] each individual employee, regardless of their position, assumes an active role in error prevention and that role is supported by the organization.


what is described here:

view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations)
identify situations or factors likely to give rise to human error and implement systems changes

systems approach


what is described here:

personnel or parts of the health care system in direct contact with patients
administering any kind of therapy (e.g., a nurse programming an intravenous pump) or performing any aspect of care

sharp end


what is described here:

many layers of the health care system not in direct contact with patients, but which influence the personnel and equipment which do contact patients

consists of those who set policy, manage health care institutions, and design medical devices, and other people and forces, which, though removed in time and space from direct patient care, nonetheless affect how care is delivered

blunt end


what is described here:

An event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). This definition is identical to that for close call.
Need to be documented

Near miss


what is described here:

discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.

human factors engineering


what is described here:

process of avoiding such inadvertent inconsistencies by reviewing the patient's current medication regimen and comparing it with the regimen being considered for the new setting of care.

med reconciliation


explain the medication error iceberg

reported errors are errors that cause actual harm and is the tip of the glacier

- unreported errors make up what's below the surface\
- Incidence in health care and med errors in health system is unknown
- Many near misses not talked about


explain the swiss cheese model

protective barriers are in place such as prescription checking, patient understanding treatment, complete prescription issued, effective communication from pros when necessary, accurate check when administered
- holes in system still exist and represent weakness and active failures, latent conditions


A person problem or a system

The person approach focuses on the errors made by individuals. The reaction to these errors tends to be to name, blame and shame. Although professionals must take responsibility for their actions, blaming does not encourage a culture of reporting or learning.

In order to function safely an organisation needs to understand its risks so that it can minimise them by building in defences and safeguards. These risks can only be identified if there is commitment to an open
culture of reporting throughout the organisation.


what is the systems approach?

accepts that humans are fallible and therefore
errors can be expected to occur – and may recur regardless of the competence of individuals
- focus on the conditions and how they predispose errors
- enables system defenses to be made


define drug incident

Any preventable event that may cause or lead to inappropriate drug use or patient harm.
Drug incidents may be related to the practice of pharmacists, techs, drugs, health care products, aids/devices, procedures, systems
◦ Prescribing;
◦ Order communications;
◦ Product labeling,
◦ Packaging, nomenclature;
◦ Compounding;
◦ Dispensing and distribution
◦ Administration
◦ Education, monitoring and use.


define drug error

Means an adverse drug event or a drug incident where the drug has been released to pt


Do all drug incidents need to be reported?

◦ No. You are not required to record a drug incident if it is discovered and corrected before the drug is released to the patient.
◦ However, if the drug incident is not discovered until after the drug has been released to the patient, it must be recorded as part of the quality assurance process. Recording is required even if the patient did not ingest any of the drug. However, you may wish to record these "near misses" to prevent them from recurring.


Do all adverse events need to be reported?

◦ Yes. All adverse drug events must be recorded as part of the pharmacy’s quality assurance process.

Not all adverse reactions need to be reported?


Quality Assurance: SOPs

As per Standard 1.9 of the Standards of Practice for Pharmacists and Pharmacy Technicians, each pharmacist and pharmacy technician must participate in the quality assurance process

Standard 6 of Standards for the Operation of Licensed Pharmacies


what were the results of an analysis of medication errors that reach the patient and “near misses”
in community pharmacy

◦ 131 031 events reported between study period
◦ 82% near misses
◦ 16% resulted in no harm (10.44% did not ingest; 5.87% ingested)
◦ 0.95% resulted in patient harm


in the analysis, where did most of the quality related events occur?

what are the common types of incidents?

◦ Order entry/transcription (58.7%)
◦ Preparation/Dispensing (29.3%)
◦ Prescribing (9.0%)

◦ Incorrect dose or frequency
◦ Incorrect duration of treatment
◦ Incorrect quantity
◦ Incorrect drug
◦ Incorrect strength


what strategies can be employed to prevent drug incidents?
specific for communication?

Clarify any therapy discrepancies before the medication is dispensed to the patient
Barcode prescription verification
Separate look‐alike drugs
Point‐check policies
“Show and tell” drugs
avoid error prone abbrev

◦ Discus near misses, errors with team members regularly
◦ Document clearly and effectively
◦ Provide clear communication when the care of a patient is transferred from one health care
professional to another


error prine abbrev

µg - Microgram
AD, AS, AU - Right ear, left ear, each ear
IN - Intranasal
IT -
Per os
SC, SQ, sq, or sub q
o.d. or OD
Q.D., QD, q.d., or qd**
Q.O.D., QOD, q.o.d., or qod
q6PM, etc.
TIW or tiw
BIW or biw

what should they be ?


how can meds be used safely at home

Safe Storage and Disposal of Medications
◦ Pharmacists have a responsibility to engage in conversation with patients about the safe storage of medications in the home and about the safe disposal of unnecessary or expired medications.
◦ Advise patient on how and where they can dispose of their medications safely.
-Keep all alcohol, drugs, and poisons out of sight.
◦ Do not take your medicines in front of your child. He or she may try to do what you do.
◦ Never leave alcohol, medicines, or household products out when you are not in the room.
◦ Guests may have medicines with them. Make sure that guests keep their bags out of the reach of your child.
◦ Do not keep products like oven cleaner and dishwasher soap under the kitchen sink.
◦ Keep products in the containers they came in. Keep the original labels on them.