Patient Safety Week Jeopardy
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Patient Safety Week Jeopardy. Click to begin. Choose a point value. Choose a point value. Click here for Final Jeopardy. The Usual Suspects. Its Gotta Be “Right”. Med Rec or Med Wreck. By The Numbers. Potporrui. 10 Point. 10 Point. 10 Point. 10 Point. 10 Point. 20 Points. - PowerPoint PPT Presentation
Transcript of Patient Safety Week Jeopardy
Click to begin.
Click here for Final Jeopardy
Its Gotta Be “Right”
By The Numbers
Potporrui
10 Point
20 Points
30 Points
40 Points
50 Points
10 Point 10 Point 10 Point 10 Point
20 Points 20 Points 20 Points 20 Points
30 Points
40 Points
50 Points
30 Points 30 Points 30 Points
40 Points 40 Points 40 Points
50 Points 50 Points 50 Points
Med Rec or
Med Wreck
The Usual Suspects
Most medication errors resulting in
harm are caused by confusing these two
drugs
What are Morphine and
Hydromorphone?
As compiled by the Institute for Safe Medication Practices Canada
This drug tops the list of medications most likely to cause harm as a consequence of a
medication error
What is Insulin?
As compiled by the Institute for Safe Medication Practices Canada
Three of the top ten drugs most likely to
cause harm as a result of a medication error
are from this class
What are
anti-coagulants
(Heparin,Warfarin, Dalteparin)
This popular antihypertensive
isn’t inhibited about being number ten on
the list
What is Ramipril?
As compiled by the Institute for Safe Medication Practices Canada
Because of its high risk potential, Health Canada
recommends disposing this top ten narcotic down
the toilet
Fentanyl Transdermal
2005 Public Advisory still on the Health Canada website
Failure to identify this “right” is rarely
involved in medication errors reported as
causing harm
What is the
“right patient”
Wrong drug and wrong dose are # 1 and # 2
To obtain the maximum benefit,
anti-Parkinson’s drugs should be given with this “right” in mind
The right time
You would have been “right” if you answered 5 to this
question before 2008
How many “rights” of safe medication
administration are there according to the College
of Nurses
Now there are 8
After making sure it’s the “right route”, this intramuscular site is
the preferred location for most adults
What is ventrogluteal?
Dorsogluteal is the least recommended
One of three new “rights” in the updated
standards, this is the one least likely to be
written in the Doctors’ Orders
What is the
right reason?
Right frequency and right site are the other two
Dr. House would have no problem breaking
into a patient’s medicine cupboard to improve a “BPMH”
What is a Best Possible
Medication History He would also have to check with their pharmacy, talk with
them and their family, contact any other healthcare providers and or institutions, and check their medication
administration record from any other unit
“ADE”
What is an adverse drug event
According to a recent Quebec study, this
percentage of ADE’s are caused by medication
“irreconciliation” between hospitals and
LTC facilities
What is 20%
95% of
What you have when the physician has made an
intentional choice to add, change the dose or route or
discontinue a medication and their choice is clearly
documented
What is an intentional discrepancy
Documented intentional discrepancies are considered best practice in medication reconciliation.
This category of discrepancies accounts for most discrepancies
and is generally not considered a “med
error”
What are “undocumented
intentional discrepancies”
An unintentional discrepancy is one in which the physician unintentionally changed the dose or route, added or omitted a
medication the patient was taking prior to admission. These are
medication errors and can lead to adverse drug events (ADEs)
At 7.5% our rate is better than many, but not better than
the rate of every country in the world
What is the percentage of persons admitted to
hospital in Canada who will experience an
adverse event
Worldwide rates are between 2.9 and 16.6
The percentage of patients in a
Canadian Hospital who will receive the wrong medication or
the wrong dose
What is 1 in 9
Medication errors rank here on the top ten list of causes of
death in North America
What is 8
In Canada, medication errors and other hospital related adverse events cause more deaths than
MVAs, breast cancer and HIV combined
3300 members of this age group die in Canada each year as a result of
a medication error
Who are the Elderly
Of between 4-8, 5-10, 9-13, 10-14, what is number of regularly
scheduled medications that residents of LTC
facilities take daily
What is 9-13
Remember, many may one day be your patient as well. With PRNs, some take as many as
21different medications as often as 4 times daily
What is Avandia
When it comes to abbreviations, this list is the most important one
to know
What is the ISMP “Do NOT Use List”
Of the major categories of infusion
pump errors, this one leads the list at
58%
What is incorrect flow rate
Over 62% of these are overdose errors
Besides beginning with the letter “G”, garlic,
ginseng, gingko biloba, ginger and green tea have this in common
What is interact with Coumadin
Decrease INR: Ginseng, green tea,
Increases INR: garlic
Inhibit platelet aggregation: ginkgo, ginger
This list of medications considered inappropriate for the elderly is named after a doctor and not a
popular drink
What is the
Beers List?
AKA the Beers Criteria, it was first compiled in 1991 and updated in 2003
Make your wager
ISMP CMIRPS Program
What is the national error reporting
mechanism that nurses may use to
anonymously report medication errors
