ergonomics, human behavior, systems thinking
What are the three factors that make up Medication Errors?
initiating therapy, monitoring therapy, managing therapy
What are the key elements to the proper functioning of the pharmaceutical care system? (3)
wrong: patient, dose/strength/frequency, formulation, quantity
What are the 5 main categories of prescribing errors?
inattentional blindness
-occurs when an individual fails to perceive an unexpected stimulus in plain sight, purely as a result of a lack of attention rather than any vision defects or deficits.
punitive
-those who make an error are held personally responsible, regardless of the root cause.
blame free
-encourage reporting of errors as there was no risk of punishment, regardless of the cause of the error.
focus is on the cause of error; errors caused by system failure are not punished; negligent behavior still punished
How is "Just Culture" different from the other types of safety cultures?
Medication misadventure
-any iatrogenic hazard or incident associated with medications
put it in a bag
When it comes to dispensing Vincristine, how do we safely administer it?
high dose, drug interaction, excessive utilization
What are some reasons that a DUR rejection may occur?
Drug utilization review
-Authorized, structured, ongoing review of prescribing, dispensing and use of medication.
ergonomics
-the study of all factors that make it easier to do work in the right way
-the interaction between humans and the system in which they work
standard operation procedures
•is a protocol which details how a certain procedure should be carried out every time it is performed.