HIM-2020 0110 Med Safety Final Exam Study Guide
Medication Safety Final Exam Study Guide
Week 1 Foundation of Med Safety
1. Identify individuals, groups, and organizations that play a role in medication safety
a. Government
1. FDA
- Approves drugs safe and effective
- Issues warnings and communications
- Medwatch ® reporting
2. Joint Commission - Accredits hospitals
- Issues patient safety goals
3. Agency for Health Care Research and Quality (AHRQ)
- Provides grant money for research
- Clinical guidelines
b. Non-government
1. World Health Organization (WHO)
- Provides directives for international health practices within the United Nations
2. Institute for Safe Medication Practices (ISMP)
- Nonprofit organization focused solely on medication safety
- NCC MERP reporting
3. Institute for Healthcare Improvement (IHI)
- Healthcare education resource
- Uses applied science in a variety of healthcare settings
2. List common classifications of medication errors including limitations of incident
reporting a. Medication use process
• Ordering - transcribing - dispensing - administration - monitoring
• Errors may occur in one or multiple steps of the process
b. General type of error
• Wrong patient • Wrong dose • Inappropriate medication • Etc.
Error
Mistake Skill-based
(planning error) (execution error)
Knowledge
Rule-based
deficit Action based Memory based
Technical
Misapplication Bad rules execution
c. National Coordinating Council for Medication Error Reporting and
Prevention (NCC-MERP)
1
P1 Fall Quarter 2020
,HIM-2020 0110 Med Safety Final Exam Study Guide
- National Coordinating Council (NCC) for Medication Error Reporting and Prevention
(MERP)
- Provides a systematic method for classifying medication errors
- Most widely adopted classification system in healthcare settings
• Used in reporting to ISMP
Limitations of NCC MERP
• Purely user generated o Around 7% of errors are actually reported
• Not all aspects purely subjective o How much harm could really occur?
o Incidents versus errors
• Time, complexity o Are “near misses” worth reporting?
• True “error rates” are difficult to detect
• Identifying a numerator and denominator
• Can not accurately measure outcome changes
• Can not compare institutions or situations well
3. Define root-cause analysis (RCA) and failure mode and effects analysis (FMEA)
a. FMEA
• Tool that can be applied to any process (not just medication safety)
• Considers Murphy’s Law (anything can go wrong)
• Looks at cause effect, likelihood statistics, and actions that can be taken to reduce the
failure rate
• Can be used to detect and track changes
• Unlike general incident reporting
• Can be done for each step in a process and viewed cumulatively
b. RCA
• A problem solving method for identifying the primary/underlying cause of an issue
• Can be used in other areas beyond medication safety
• Root cause: removal of the identified “cause” results in prevention of the event occurring
• An associated factor may affect, but not remove with certainty, outcome recurrence
4. Evaluate a medication-related incident using the NCC-MERP algorithm
2
P1 Fall Quarter 2020
,HIM-2020 0110 Med Safety Final Exam Study Guide
Week 2 CRM
Objective 1: Explore link between aviation safety and management/leadership and
health care
safe
ty.
• Aviation and health care are both highly complex systems that involve high levels of risk,
multiple parts, as well as high cost inputs, throughputs, and outputs
• Human factors (the decisions that individuals make) can affect both at varying points in the
system • In aviation, case studies are available of individual incidents that help improve
aviation. Many of those cases involve human factors that can be applied to other professions
(like health care) • 2016 mortality data:
- Health care: ~250,000 Americans died from medical errors (~650/day)
- Aviation: 325 people worldwide died in airplane incidents (<1/day)
-Incident analysis should have a non-punitive approach in each
Objective 2: Discuss the five hazardous attitudes, including how they occur and are
propagated in culture.
• Five Hazardous Attitudes – AIIMR
1. Anti-authority: Found in people who don’t like anyone telling them what to do -
“Don’t question me. Just do what I say.”
2. Impulsivity: Need to accomplish a task immediately, whatever the reason - “Do it
NOW. No need to double-check.”
3. Invulnerability: Impossible to harm - “It could never happen to me.”
4. Macho: Taking unnecessary risks to “prove” oneself - “I’m an expert. I know how
to do it.”
5. Resignation: People who do not see themselves as being able to make a
difference. “Why care?
I can’t change anything anyway.”
Objective 3: From scenarios, determine which of the five hazardous attitudes is being
displayed.
1. “She doesn’t know what she’s talking about, telling me how to run my store.” Anti-authority
2. “Look, this lady’s been waiting for over an hour. Just skip the second verification.”
Impulsivity
3. “I graduated top of my class & got a perfect score on the NAPLEX. I don’t make mistakes.”
Invulnerability
4. “I bet I can check 200 prescriptions in an hour. Watch me!” Macho
5. “This doctor’s office is so awful, it doesn’t matter how many times I call. I’ll just let this
second insulin prescription go through and the patient can figure it out.” Resignation
Objective 4: History & concepts of CRM, including situational awareness, effective
communications, and group dynamics
• FIRST – Understanding CRM requires accepting a few key facts: o Responsibility
for patient care rests with the entire team.
3
P1 Fall Quarter 2020
Medication Safety Final Exam Study Guide
Week 1 Foundation of Med Safety
1. Identify individuals, groups, and organizations that play a role in medication safety
a. Government
1. FDA
- Approves drugs safe and effective
- Issues warnings and communications
- Medwatch ® reporting
2. Joint Commission - Accredits hospitals
- Issues patient safety goals
3. Agency for Health Care Research and Quality (AHRQ)
- Provides grant money for research
- Clinical guidelines
b. Non-government
1. World Health Organization (WHO)
- Provides directives for international health practices within the United Nations
2. Institute for Safe Medication Practices (ISMP)
- Nonprofit organization focused solely on medication safety
- NCC MERP reporting
3. Institute for Healthcare Improvement (IHI)
- Healthcare education resource
- Uses applied science in a variety of healthcare settings
2. List common classifications of medication errors including limitations of incident
reporting a. Medication use process
• Ordering - transcribing - dispensing - administration - monitoring
• Errors may occur in one or multiple steps of the process
b. General type of error
• Wrong patient • Wrong dose • Inappropriate medication • Etc.
Error
Mistake Skill-based
(planning error) (execution error)
Knowledge
Rule-based
deficit Action based Memory based
Technical
Misapplication Bad rules execution
c. National Coordinating Council for Medication Error Reporting and
Prevention (NCC-MERP)
1
P1 Fall Quarter 2020
,HIM-2020 0110 Med Safety Final Exam Study Guide
- National Coordinating Council (NCC) for Medication Error Reporting and Prevention
(MERP)
- Provides a systematic method for classifying medication errors
- Most widely adopted classification system in healthcare settings
• Used in reporting to ISMP
Limitations of NCC MERP
• Purely user generated o Around 7% of errors are actually reported
• Not all aspects purely subjective o How much harm could really occur?
o Incidents versus errors
• Time, complexity o Are “near misses” worth reporting?
• True “error rates” are difficult to detect
• Identifying a numerator and denominator
• Can not accurately measure outcome changes
• Can not compare institutions or situations well
3. Define root-cause analysis (RCA) and failure mode and effects analysis (FMEA)
a. FMEA
• Tool that can be applied to any process (not just medication safety)
• Considers Murphy’s Law (anything can go wrong)
• Looks at cause effect, likelihood statistics, and actions that can be taken to reduce the
failure rate
• Can be used to detect and track changes
• Unlike general incident reporting
• Can be done for each step in a process and viewed cumulatively
b. RCA
• A problem solving method for identifying the primary/underlying cause of an issue
• Can be used in other areas beyond medication safety
• Root cause: removal of the identified “cause” results in prevention of the event occurring
• An associated factor may affect, but not remove with certainty, outcome recurrence
4. Evaluate a medication-related incident using the NCC-MERP algorithm
2
P1 Fall Quarter 2020
,HIM-2020 0110 Med Safety Final Exam Study Guide
Week 2 CRM
Objective 1: Explore link between aviation safety and management/leadership and
health care
safe
ty.
• Aviation and health care are both highly complex systems that involve high levels of risk,
multiple parts, as well as high cost inputs, throughputs, and outputs
• Human factors (the decisions that individuals make) can affect both at varying points in the
system • In aviation, case studies are available of individual incidents that help improve
aviation. Many of those cases involve human factors that can be applied to other professions
(like health care) • 2016 mortality data:
- Health care: ~250,000 Americans died from medical errors (~650/day)
- Aviation: 325 people worldwide died in airplane incidents (<1/day)
-Incident analysis should have a non-punitive approach in each
Objective 2: Discuss the five hazardous attitudes, including how they occur and are
propagated in culture.
• Five Hazardous Attitudes – AIIMR
1. Anti-authority: Found in people who don’t like anyone telling them what to do -
“Don’t question me. Just do what I say.”
2. Impulsivity: Need to accomplish a task immediately, whatever the reason - “Do it
NOW. No need to double-check.”
3. Invulnerability: Impossible to harm - “It could never happen to me.”
4. Macho: Taking unnecessary risks to “prove” oneself - “I’m an expert. I know how
to do it.”
5. Resignation: People who do not see themselves as being able to make a
difference. “Why care?
I can’t change anything anyway.”
Objective 3: From scenarios, determine which of the five hazardous attitudes is being
displayed.
1. “She doesn’t know what she’s talking about, telling me how to run my store.” Anti-authority
2. “Look, this lady’s been waiting for over an hour. Just skip the second verification.”
Impulsivity
3. “I graduated top of my class & got a perfect score on the NAPLEX. I don’t make mistakes.”
Invulnerability
4. “I bet I can check 200 prescriptions in an hour. Watch me!” Macho
5. “This doctor’s office is so awful, it doesn’t matter how many times I call. I’ll just let this
second insulin prescription go through and the patient can figure it out.” Resignation
Objective 4: History & concepts of CRM, including situational awareness, effective
communications, and group dynamics
• FIRST – Understanding CRM requires accepting a few key facts: o Responsibility
for patient care rests with the entire team.
3
P1 Fall Quarter 2020
