PHARMACOLOGY EXAM III

Module 4 Medication Safety Risk Reduction Strategies: 1. Prevention: Reduce or eliminate the possibility of error 2. Detection: Make errors visible. Make it easier for people to do the right thing. 3. Mitigation: Identify errors quickly and take appropriate action. Minimize the consequences of errors. High Alert Medications: Medications that have a high risk of causing patient injury when misused. All hospitals required to have a list with associated risk reduction strategies. Usually included: Electrolytes, chemo, narcotics/sedatives, insulin, anticoagulants, NMBAs Medication Error Pitfalls: 1. Abbreviations 2. Look-alike/Sound-alike (LASA) drugs 3. Distractions and interruptions 4. Tubing/line mix-ups 5. Patient ID/eMAR 6. Failure to monitor/rescue 7. Lack of accurate/documented weights 8. Medication reconciliation Error Reporting: Ø National reporting o FDA MedWatch o ISMP MERP Ø Local reporting Confirmation Bias: The tendency to filter information to retain only what conforms to one’s preferences, and to reject information that does not. We see and hear what we want to see and hear. Unacceptable Acceptable U IU QD μg CC QOD 1.0 .5 MS MSO4 MgSO4 TIW Units International units Daily, everyday Microgram mL every other day 1 0.5 Morphine Morphine Magnesium sulfate Three times a week PHARMACOLOGY EXAM III