Medication Safety/Quality Assurance

Medication

Safety

/Quality
Assurance

Medication Errors

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Every pharmacy has its own set of standards

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Community pharmacy “traps”

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Professional practice

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Health care products

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Procedures

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Systems

Reducing Errors

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Automation has significantly reduced errors

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Automated dispensing machine (ADM) and floor stock

Word Cloud

Name 2 community pharmacy "traps"

Medication Errors Best Practices

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Continually ask pt. for updates

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Clarify prescriptions w/ pharmacist

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Select medication based on hard copy

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Notify pharmacist of electronic notifications

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Use verifications (NDC #)

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Verify stock

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Use barcodes w/ total parenteral nutrition (TPN)

Medication Errors Best Practices (cont.)

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Count twice

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2 pt. Identifiers (Pick up AND managing meds)

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Offer counseling (OBRA ‘90)

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Order floorstock on preprinted order forms

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Draw up long-acting insulin in pt. Specific syringes

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When using ADM verify before putting in pocket

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Nursing unit monthly checks

Medication Errors Best Practices (cont.)

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Pharmacist double check w/ chemo meds

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Pt. weight in kg

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Annual skill demonstrations (written/skill)

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Pharmacy and therapeutics (P&T) committees

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Check pt. INR prior to dispensing warfarin

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Check hematocrit levels prior to dispensing epoetin alfa

Fill in the Blanks

Select medication based on the

Multiple Choice

What is true about total parenteral nutrition (TPN)?

• Use barcodes

• Confirm w/ pharmacist

• It is delivered orally

• Orders must confirmed via hard copy

Match

Match the error prevention with it's fact

• OBRA '90

• Floor stock

• Long acting insulin

• Chemo. Meds

• Pt. INH

Guarantee counseling by pharmacist

Ordered on preprinted forms

Drawn up in pt. specific syringes

Must have pharmacist check

Checked prior to admin. warfarin

• Guarantee counseling by pharmacist

• Ordered on preprinted forms

• Drawn up in pt. specific syringes

• Must have pharmacist check

• Checked prior to admin. warfarin

Medication Adherence

Day’s
Supply

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Provider
changed dose

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Pt. is taking to
much

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Pt.
misunderstands
instructions

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Pt. is diverting
or abusing
medication

“Refill
to soon”

Database to
research
trends in
controlled
substance use

Prescriptio n
Monitoring

Program
(PMP)

Number dispensed

number of doses per
day

Fill in the Blanks

What is the daily supply of the sig below? (type number only)

po bid dispense #60

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Right Medication

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Right route

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Right time

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Right pt.

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Right dose

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Right documentation

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Right response

5 Rights

Patient Information

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Verify spelling of pt. name

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Pt. address

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Make sure you can read physician
name

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Verify/document address on script

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Double check for suspicious activity

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Liquid meds verify pt. weight
(especially peds)

Prescription Delivery

Potential Errors

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Report near misses and errors
IMMEDIATELY

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Root Cause analysis

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Continuous quality improvement
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(CQI)

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Be discrete

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Document
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ISMP Medication/Vaccine
Error Reporting Program
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(MERP)

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(VERP)

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MedMARx

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FDA Adverse/Vaccine Event
Reporting System (FAERS)
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MedWatch

Reorder

Place the prescription delivery steps in the correct order.

• Verify number of prescriptions being picked up and deographics

• Check prescription

• Check recipt for 3rd party info.

• Inform pt. they can speak w/ pharmacist and answer their questions

• Complete the sale

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