Transcript Patient Safety Week Jeopardy game

Click to begin.
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
20 Points
20 Points
20 Points
20 Points
30 Points
30 Points
30 Points
30 Points
30 Points
40 Points
40 Points
40 Points
40 Points
40 Points
50 Points
50 Points
50 Points
50 Points
50 Points
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