Medication Safety and Quality Improvement Flashcards

According to ISMP's hierarchy of error-reduction strategies, which intervention is considered MOST effective?

Answer: Forcing functions and constraints

Forcing functions physically prevent the error, making them stronger than people-dependent strategies like education or checklists.

In Failure Mode and Effects Analysis (FMEA), the Risk Priority Number (RPN) is calculated by multiplying which three factors?

Answer: Severity, occurrence, and detectability

RPN = severity x occurrence (likelihood) x detectability, used to prioritize failure modes.

Under the Just Culture model, how should a pharmacist's at-risk behavior (e.g., routinely bypassing a barcode scan to save time) be managed?

Answer: Coaching to understand and remove the incentive for the drift

At-risk behavior is managed with coaching, human error with consoling, and reckless behavior with remedial or disciplinary action.

Which NCC MERP category describes a medication error that reached the patient and caused temporary harm requiring intervention?

Answer: Category E

Category E is temporary harm requiring intervention; C and D reached the patient without harm.

A run chart shows 6 consecutive data points above the median after a dispensing workflow change. What does this pattern indicate?

Answer: A shift suggesting a non-random signal

Six or more consecutive points on one side of the median is a shift, a non-random signal of change.

Which abbreviation is on The Joint Commission's official 'Do Not Use' list?

Answer: q.d.

Q.D. and Q.O.D. are on the Do Not Use list because they are confused with each other and with QID.

Which framework explains how errors occur when holes in multiple layers of defense align, allowing a hazard to reach the patient?

Answer: Swiss cheese model

James Reason's Swiss cheese model describes latent and active failures aligning across system defenses.