Introduction
This module will explore the current practice emphasis on reduction of medication errors by health care providers. Selected databases will be explored with attention to the medications most often linked to medication errors in practice today.
Objectives
1. Identify strategies used to reduce medication errors and/or adverse drug events.
2. Describe the systematic process of a failure modes effects analysis (FMEA) and a root cause analysis (RCA).
Learning Activities
Readings
Failure Modes and Effects Analysis (FMEA) Readings
https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis
http://www.ihi.org/Workspace/tools/fmea/
Medication Safety Readings
Please explore the following websites. These websites contain good information regarding medication errors. The objectives will help guide your reading.
http://www.jointcommission.org/ (review current Sentinel Event Alerts under topics)
https://www.fda.gov/Drugs/ResourcesForYou/HealthProfessionals/default.htm (review various topics of interest for healthcare professionals—it is important to stay current on drug recalls, drug safety communication, etc.)
http://www.ismp.org (explore the site)
http://www.nccmerp.org/ (explore the site)
2018 Summer Page 2 of 2 NURS4347
Module A Evaluating Risk in Healthcare
Module A Assignments
Pre-Course quiz:
Complete the brief pre-course quiz to assess baseline of knowledge over practices involving safety, communication, and critical thinking. You have 30 minutes to complete the quiz.
Adverse Drug Event/Failure Modes and Effects Analysis (FMEA) Assignment:
Your assignment is to write a paper at least two pages in length summarizing an adverse drug event that all nurses should be concerned about and submit to the assignment link. Choose a drug that is important to YOU. For example, some students select Pitocin, while some students select hydromorphone or insulin. Be sure you provide the following information in your paper:
1. Does the Adverse Drug Event (ADE) occur due to route, time, dosage, storage, look alike sound alike error?
2. Provide statistics regarding this ADE.
3. What are some methods that can be implemented to prevent this ADE?
4. If you worked in Risk Management, would you choose to do a Root Cause Analysis (RCA) or a Failure Modes Effects Analysis and explain your rationale?
5. If you were forming a patient safety team as a leader of an FMEA, what healthcare disciplines would you place on your team and why?
Clinical Experience:
Interview a pharmacist and determine your facility’s policy for reporting medication errors. Discuss ways to prevent medication errors and methods to encourage reporting medication errors. This paper must have a correctly-formatted title page. If you do not have access to a pharmacist at your facility, please email the course facilitator and we can assist you in finding an appropriate individual to interview.
1. The interview should be no less than two pages in length.
2. Clinical experiences need to be face-to-face (may use Skype) unless prior approval has been given
3. In addition to the personal communication reference, a minimum of two professional and scholarly references are required for proficient on the grading rubric, and three or more professional and scholarly references required for expert level on the grading rubric. References should be no more than five years old.
4. This assignment will also give the student credit for the Interprofessional Practice and Education Activity (IPE), which is required to graduate. The student must earn a minimum grade of 70 in order to pass the activity. If the student does not achieve a score of at least a 70, the student must repeat the assignment with the maximum grade awarded being a 70. The IPE activity can be repeated only one time.