Sample CCRM Medication Safety SAQ

8/13/2019 Sample CCRM Medication Safety SAQ

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VOLUME 2

January 2008

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Medication Safety

Self-Assessment QuestionnaireSelf-Assessment Questionnaires 10

Continuing CareRisk Management

Initial assessment by: Date:

In consultation with:

Date of previous

assessment:

Medication safety is a top priority for long-term care facilities, and the reasons are clear: the harm to residents from

medication errors is great, the cost of such errors to society is high, and accrediting organizations, federal agencies,

and third-party payers expect facilities to adopt the numerous strategies currently available to prevent medica-

tion errors. Therefore, reducing the frequency and severity of medication errors and adopting strategies to prevent

adverse drug events are ongoing goals for facilities. Because medication errors can involve many groups—

physicians, nurses, pharmacists, and even self-medicating residents—risk managers must help their facilities

adopt a multidisciplinary approach to medication error reduction.

The Continuing Care Risk Management (CCRM) System has prepared this Self-Assessment Questionnaire (SAQ)to help risk managers evaluate their facilities’ policies and procedures regarding medication safety. Although

extensive, this SAQ does not address all the medication management issues that accrediting organizations and state

and federal regulations may require facilities to address. CCRM recommends that this questionnaire be completed

initially to acquire baseline data and periodically thereafter to assess progress.

Some of the resources used in the development of this SAQ are included in the list preceding the assessment

questions. This list of resources is not intended to be comprehensive, but it does reflect important standards,

guidelines, and other documents that underlie various questions. For example, medication safety agencies, such as

the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia (USP), have contributed extensively to

the field of medication safety and are cited here. For additional information, refer to the Risk Analysis “Medication

Safety” in the Patient/Resident Care section of the CCRM System.

42 CFR § 483.25 (2000).•American Nurses Association (ANA). 2007 study of injectable medication errors [online]. [cited 2007 Jul 16].•

Available from Internet: http://www.nursingworld.org.

American Society of Consultant Pharmacists (ASCP):•

Drug regimen review [online]. [cited 2007 Jul 20]. Available from Internet: http://www.ascp.com/resources/drr.—

Guidelines on preventing medication errors in pharmacies and long-term care facilities through reporting and ⎯

evaluation [online]. 1997 Jul [cited 2007 Jul 17]. Available from Internet: http://www.ascp.com/resources/

policy/upload/Gui97-Med%20Errors.pdf.



CONTINUING CARE RISK MANAGEMENT

©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 20082

Self-Assessment Questionnaires 10

Statement on preventing medication errors in pharmacies and long-term care facilities [online]. 1997 Jul [cited—

2007 Jul 20]. Available from Internet: http://www.ascp.com/resources/policy/upload/Sta97-Med%20Errors.pdf.

American Society of Health-System Pharmacists (ASHP):•

ASHP guidelines on preventing medication errors with antineoplastic agents.— Am J Health Syst Pharm 2002 Sep

1;59(17):1648-68.

The medication-use-system safety strategy (MS— 3). Introduction and task analysis [online]. 2001 [cited 2007 Jun13]. Available from Internet: http://www.ashp.org/s_ashp/bin.asp?CID=1001&DID=6347&DOC=FILE.PDF.

Commission on Accreditation of Rehabilitation Facilities—Continuing Care Accreditation Commission•

(CARF-CCAC). 2006 CARF-CCAC ASPIRE to excellence standards manual with survey preparation questions. July 1,

2006—June 30, 2007. Washington (DC): CARF-CCAC; 2006.

Institute for Safe Medication Practices (ISMP):•

Intimidation: practitioners speak up about this unresolved problem [online]. ISMP Med Saf Alert 2004—

Mar 11 [cited 2007 Aug 31]. Available from Internet: http://www.ismp.org/newsletters/acutecare/

articles/20040311_2.asp.

ISMP’s list of high-alert medications [online]. [cited 2007 Jun 11]. Available from Internet: http://www.ismp.—

org/Tools/highalertmedications.pdf.Medication safety contest winner. Policy for a non-punitive, system-based error reporting program. Frederick—

Memorial Hospital, Frederick, Maryland [online]. ISMP Med Saf Alert 2004 Mar 11 [cited 2007 Jun]. Available

from Internet: http://www.ismp.org/Tools/FrederickReporting.asp.

Pharmacy interventions: part II from ISMP survey.— ISMP Med Saf Alert 2002 Jul 10;7(14):1-2.

Institute of Medicine (IOM).• Preventing medication errors. Committee on Identifying and Preventing Medication

Errors. Washington (DC): National Academies Press; 2007.

Joint Commission:•

Comprehensive accreditation manual for long-term care: official handbook. ⎯ Oakbrook Terrace (IL): Joint Commission

Resources; 2005-2006.

Sentinel event statistics—March 31, 2007 [online]. [cited 2007 Aug 29]. Available from Internet: http://www. ⎯

jointcommission.org/SentinelEvents/Statistics.

Joint Commission Resources (JCR):•

Accreditation issues for risk managers. Oakbrook Terrace (IL): JCR; 2004. ⎯

Medication station: conducting FMEA for medication management [online]. [cited 2007 Jun 12]. Available ⎯

from Internet: http://www.jcrinc.com/6629.

Kohn LT, Corrigan JM, Donaldson MS, eds.• To err is human: building a safer health system. Washington (DC):

National Academies Press; 1999.

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP):•

Statement from NCC MERP: use of medication error rates to compare health care organizations is of no value ⎯

[online]. [cited 2007 Jul 11]. Available from Internet: http://www.nccmerp.org/council/council2002-06-11.html.

What is a medication error? [online]. [cited 2007 Jun 4]. Available from Internet: http://www.nccmerp.org/ ⎯

aboutMedErrors.htm.

National Quality Forum (NQF). Safe practices for better healthcare. 2006 update [consensus report]. Washington•

(DC): NQF; 2006.

U.S. Government Accountability Office (U.S. GAO). Assisted living: quality-of-care and consumer protection•

issues in four states. GAO/HEHS-99-27. Washington (DC): GAO; 1999.

U.S. Pharmacopeia (USP):•

Examining medication errors that occur in the resident’s home. USP Resident Safety CAPSLink [online]. 2004 ⎯

Mar [cited 2007 Jun 28]. Available from Internet: http://www.usp.org.



CONTINUING CARE RISK MANAGEMENT Self-Assessment Questionnaires 10

©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 3

Improving the safety of automated dispensing devices. USP Resident Safety CAPSLink [online]. 2007 Jan ⎯

[cited 2007 Jun 18]. Available from Internet: http://www.usp.org.

Medication errors frequently asked questions [online]. [cited 2007 Jul 16]. Available from Internet: ⎯

http://www.usp.org.

Leadership

1. Does the governing body receive periodic

reports on medication safety activities

and initiatives?

2. Do the medical director, director of

nursing, and facility administrator dem-

onstrate support for medication safety?

3. Do those in leadership, managerial, or

supervisory roles demonstrate com-

mitment to a “just culture,” in which

reported errors are viewed as an oppor-

tunity for systems evaluation and

improvement?

4. Is leadership support for the prevention

of medication errors demonstrated by

a. allocation of resources needed to

assess, plan for, implement, and

monitor safe-drug-use systems in the

institution?

b. implementation of policies and

systems that support medication

error and near-miss reporting in a

fair and just environment?

c. provision of feedback to caregivers

on how error and near-miss

reporting has resulted in system

improvements to prevent recurrence

and unsafe processes?

d. establishment of a medication safety

recognition program whereby those

who report unsafe medication

practices and/or are involved in

reducing potential medication errors

are rewarded for their efforts?

e. discouragement of institutional

environments in which open

communication is inhibited and/or

intimidation prevails?

*N/I stands for “Needs Improvement.”

YES NO N/I* N/A COMMENTS

(continued






YES NO N/I N/A COMMENTS

5. Are caregivers encouraged to question

or clarify potentially unsafe medication

orders without fear of retribution, intimi-

dation, or disrespect? 5.1. Do facility administrators consider the

identification and correction of such an

intimidating environment a high priority?

6. Does leadership support the preven-

tion of medication errors by conducting

walkarounds in resident care areas?

6.1. On these walkarounds, is information

about unsafe practices solicited from

frontline clinicians and caregivers?

6.2. Do these walkarounds result in periodicfeedback from leadership to frontline cli-

nicians regarding the steps being taken to

improve medication safety?

7. Does the risk manager work with the

facility’s administrators, clinicians, and

educators to promote effective communi-

cation among caregivers involved in the

medication management process?

Policies and Procedures

8. Are policies related to medication safety

created by multidisciplinary teams

including representation from nursing,

medical, pharmacy, risk management,

and quality improvement staff?

9. Do the facility’s medication safety poli-

cies and procedures comply with state

and federal regulations and address

a. resident-specific information?

b. selection and procurement?

c. storage?

d. ordering and transcription?

e. preparation and dispensing?

f. administration?

g. monitoring?

h. high-risk medications?

i. evaluation?

j. reporting of errors and near misses?





(continued



10. Do these policies and procedures also

a. establish who may administer

medications, consistent with

applicable laws and regulations?

b. provide criteria for determining

what medications are made available

for dispensing or administration?

c. define a process for handling drug

shortages?

d. define a process for approving and

procuring new medications?

e. address the use of multiuse vials

and describe the steps necessary to

prevent vial contamination?

11. Do the policies specify medication ad-

ministration procedures that include

a. the use of two unique identifiers for

resident identification?

b. verification of drug and dose?

c. independent checks for dose

calculation when applicable?

d. verification of the route of

administration?

12. Does the facility have a method to track

compliance with its policies?

Storage

13. Are medications stored in a secure man-

ner to prevent unauthorized access?

14. Are look-alike/sound-alike drugs stored

in a segregated manner to prevent acci-

dental interchange?

15. Does the facility conduct an annual reviewof identified look-alike/sound-alike drugs

and strategies used to prevent accidental

interchange of the drugs?

16. Are stored drug concentrations limited

and standardized?

17. Have concentrated electrolytes been

removed from resident care areas?







18. Are periodic pharmacy inspections

conducted

a. to evaluate drug stock and

maintenance of emergencymedications and supplies?

b. to evaluate storage of medications

that residents bring into the facility?

19. Do the facility’s procedures for the safe

storage and handling of medications

include the following:

a. Standardized methods for labeling,

packaging, and storing medications?

b. A requirement that medications

remain labeled until they areadministered to residents?

c. Routine pharmacy review of

automated or nonautomated

dispensing cabinets and unit stock

to identify and dispose of expired,

damaged, or contaminated medications?

d. Segregation of expired, damaged, or

contaminated medications until they

are removed from the facility?

e. Use of TALLman* lettering?

20. Are the following steps taken to mini-

mize the risks of mix-ups of different

strengths of the same medication:

a. Purchase of different strengths of

the same medication from different

suppliers to avoid similarities in

packaging and labeling?

b. Separate storage of different

strengths of the same medication?

c. Use of warning labels on different

strengths of the same medication to

alert users to the potential for mix-ups?

Medication Ordering and Transcription

21. Do all orders and transcriptions for medi-

cation specify a diagnosis, condition, or

indication?

* TALLman lettering is the practice of highlighting sections of drug names using uppercase letters. Examples include DOBUTamine/DOPamineand vinBLASTine/vinCRISTine.





(continued



22. Are medication orders clearly written

and accurately transcribed?

23. Does the facility communicate to care-

givers and have written policies and

procedures to address the specific ele-

ments of a complete medication order?

Illegible Handwriting, Verbal or TelephoneOrders, and Abbreviations

24. When an order is ambiguous, incomplete,

irregular, or illegible, are nurses and

pharmacists required to contact the pre-

scribing physician and ask for clarification?

24.1. Does the facility prohibit the filling ofsuch orders until clarification is obtained?

25. Does the facility’s leadership help foster a

culture in which professionals do not feel

intimidated about questioning orders or

pressured into carrying out questionable

orders?

26. Are policies regarding verbal and tele-

phone orders in compliance with state

and federal regulations and accreditation

standards?

27. Does the facility have a policy and proce-

dure in place for taking telephone orders?

27.1. Is the identity of a prescriber giving a

telephone order verified to ensure that

he or she is an authorized prescriber?

27.2. Is the identity of the resident verified

using two unique identifiers before tele-

phone orders are accepted for the resident?

28. Is an order written or keyed directly into

the resident’s medical record as it is being received?

28.1. Does the person taking the order read it

back verbatim to the prescriber to verify

what was written in the medical record?

28.2. Is the information entered into the resi-

dent’s medical record signed and dated

by the person taking the order?







28.3. Does the prescriber verify, sign, and date

the order within a specified time frame?

29. Does the facility maintain a list of pro-

hibited abbreviations, acronyms, and

symbols that are known to increase the

risk of miscommunication and dosage

errors (e.g., the use of “U” for units and

“qd” for daily)?

29.1. In preparing the list of prohibited abbre-

viations, acronyms, and symbols, has the

facility reviewed recommendations of

prohibited abbreviations from organiza-

tions such as ISMP, NCC MERP, and

the Joint Commission?

29.2. Does the facility require clinicians to

avoid using prohibited abbreviations in

their medication orders and other resi-

dent-specific documentation?

29.3. Does the facility have mechanisms in

place to ensure clinicians’ compliance

with the list of prohibited abbreviations

(e.g., provision of feedback to a practitio-

ner if a prohibited abbreviation is used)?

29.4. When an unacceptable abbreviation

is used for a medication order, do

responsible staff members (e.g., nurses,

pharmacists) verify the order with the

prescriber before it is filled?

Medication Preparation and Dispensing

30. Are all medication orders reviewed by a

pharmacist before medication is removed

from stock or an automated storage and

distribution device?

30.1. If a pharmacist is not available, are

licensed independent practitioners (LIPs)

allowed to control the ordering, prepara-

tion, and administration of medication?

30.2. If the situation is urgent and a delay

would harm the resident, are LIPs

allowed to control the ordering, prepara-

tion, and administration of medication?





(continued



30.3. Are these reviews conducted in a manner

that does not unduly delay administra-

tion of medication?

30.4. If a pharmacist is not available to reviewa medication, does the pharmacist review

these orders as soon as possible once the

pharmacy reopens?

30.5. Is the pharmacist’s review of the medica-

tion order documented in the resident’s

record?

31. Are sterile medication and intravenous

admixtures prepared in the pharmacy?

32. Are there provisions for obtaining medi-

cations when the pharmacy is closed?

33. Is there a process in place for handling

recalled and discontinued drugs?

34. Is there a process in place for handling

drugs that are returned to the pharmacy?

35. Is standardized labeling used?

36. Are there labeling specifications in

place for

a. medications that are prepared but

not immediately administered?

b. individualized medications for

multiple specific residents?

37. Is a drug history (including prescription

and over-the-counter medications, vita-

mins and nutritional supplements, herbal

and alternative medications, and home

remedies) obtained and documented for

all residents upon admission?

37.1. Is a complete list of the resident’s cur-

rent (home) medications obtained upon

admission or entry to the facility? 37.2. Is resident compliance with the medi-

cation regimen (as indicated by the

medication list) assessed (i.e., is the resi-

dent taking the medications as prescribed)?

37.3. Are medications that are ordered for the

resident compared to the home list (recon-

ciled), and are any discrepancies resolved?







37.4. Is the current medication list updated

when medication reconciliation is

completed?

38. Are measures in place to prevent medi-cations from being dispensed before a

resident’s allergies have been identified

and documented?

Medication Administration

39. When conducting an assessment of

a resident’s medication practices, do

caregivers

a. identify all medication-taking

behaviors?

b. evaluate the success of the

medication regimen?

c. detect the presence and risk of

adverse medication effects?

d. educate the resident or family

members on medication regimens?

e. assess the resident’s medication-

taking behaviors, including daily

medication regimen (e.g., timeliness);

whether he or she is taking any other

treatments, using other remedies,or taking a different individual’s

prescription; and when and where

prescriptions are filled?

f. assess the resident’s comprehension

of the medication, including what

symptoms led the healthcare

provider to prescribe it and what the

medication is for, when to take it,

and when to refill the prescription?

g. request that the resident or family

members bring all of his or hermedications to the location where

the medication regimen assessment

takes place?

40. Is the following resident information

available to caregivers who are adminis-

tering medications:

a. Age?

b. Sex?





(continued



c. Current medications?

d. Diagnoses?

e. Conditions and comorbidities?

f. Relevant laboratory values?

g. Allergies and sensitivities?

h. Other information as appropriate

such as weight and height?

41. Are residents’ identities consistently veri-

fied before medication is administered?

41.1. Are at least two unique resident identi-

fiers (e.g., name, medical record number)

used to verify resident identity?

41.2. Does the facility prohibit caregivers fromusing the resident’s room number as a

resident identifier?

42. Do caregivers who administer

medications

a. verify that the medication selected

for administration is correct when

checked against the medication order

and the medication label?

b. ensure medication integrity by visual

inspection and by a check of theexpiration date?

c. verify that there are no

contraindications?

d. ensure that the medication is

administered at the right time, in the

prescribed dose, and via the right route?

e. educate the resident and/or family

about potential adverse reactions

and instruct them to watch for these

reactions?

f. communicate any concerns aboutthe medication to the resident’s

physician or other providers

and resolve any problems before

administering the medication?

g. notify prescribers in accordance with

policies and procedures in the event

of an adverse reaction?







43. When using multiuse vials, do caregivers

a. read the label to ensure that the

vial contains a preservative and is

multiuse and that the expiration date

has not passed?

b. inspect the vial for any discoloration,

turbidity, particulate matter, or

precipitates and discard the vial if

there is any evidence of contamination?

c. follow hand hygiene practices before

beginning the task?

d. clean the stopper with 70% alcohol

before a needle or other device isinserted?

e. use only sterile needles or other

devices (e.g., spike) to access the vial?

f. avoid touching the stopper?

g. store the vial in a secure refrigerator

after it is opened?

Medication Monitoring

44. Are caregivers monitored through direct

observation or other means periodically

during medication preparation, dispens-

ing, and administration for compliance

with facility policies?

45. Are caregivers required to monitor the

effects of medications on residents?

46. Are caregivers required to take into

account the resident’s perceptions about

efficacy or side effects of medication?

High-Risk Medications

47. Does the facility have a process in place

to identify high-risk or high-alert medica-

tions, which have a higher risk of causing

errors or other adverse outcomes or a

narrow margin of safety (e.g., insulin,

opiates and narcotics, anticoagulants,

concentrated electrolytes)?





(continued



48. Has the facility implemented strategies

such as the use of preprinted orders,

safety checklists, and independent

double checks to support the safe use ofhigh-risk or high-alert medications?

49. Is there a management process to pre-

vent the occurrence of errors and critical

events involving these medications?

50. Are there special procedures for handling

high-risk medications (e.g., heparin,

warfarin, insulin, potassium chloride

injection concentrate, narcotics and

opiates) throughout all steps in the medi-

cation process?

51. Do safety protocols for high-alert medica-

tions include the following:

a. Use of warning labels and cautionary

messages on computer screens?

b. Independent verification of the drug

against the order?

c. Prompt removal of discontinued

drugs and solutions and return to

the pharmacy?

Medication Safety Strategies

52. Has a baseline assessment been conducted

to help the facility focus medication

improvement efforts on identified

priorities such as medication event

identification and reporting, high-alert

medications, medication safety education,

and the elimination or reduction of dan-

gerous abbreviations and verbal orders?

53. Is there a process in place to review rec-

ommendations related to medication

safety from external sources and agencies

(e.g., American Society of Consultant

Pharmacists, American Medical Directors

Association, ECRI Institute, ISMP, Joint

Commission, National Quality Forum,

USP) on a regular basis?







53.1. Is there a process to implement recom-

mendations from outside agencies that

are appropriate for the facility?

53.2. If recommendations are not adopted, are

the reasons documented?

54. Are policies and procedures in place to

address medication recalls or discontinu-

ations by manufacturers or the U.S. Food

and Drug Administration (FDA)?

55. Have medication management processes

throughout the facility been proactively

assessed for the following risk points:

a. Availability of resident information

for the prescriber to consider whenordering drug therapy?

b. Access to current drug information,

contraindications, and potential

interactions?

c. Communication of medication

regimens during resident transfer?

56. Have technological interventions such as

the following been considered as preven-

tion strategies:

a. Computerized provider order-entrysystems?

b. Bar-coding systems?

c. Decision support systems?

d. Pharmacy information systems?

57. If a decision is made to use technological

interventions, does the facility

a. set clear objectives and goals for the

system and identify baseline data

to measure goal achievement after

implementation?

b. include all caregivers involved in

medication management when

assessing the role of technology in

the current medication-use process?

c. match the technology to the

workflow process when possible but

modify the work process in order

to capitalize on the technology’s

advantages and safeguards?





(continued



d. develop a detailed flowchart of

the medication-use process and

determine workflows before and

after implementing the technology?

e. use human factors analysis

techniques in the implementation

of new technologies to reduce

workarounds used because of a

poor system/user fit?

f. provide users with training and

education about the new system

and its appropriate use?

g. emphasize teamwork and effective

communication among caregivers?

58. Are automated dispensing units (ADUs)

used as part of an overall automated

medication management system that

generally requires pharmacy review and

order entry before caregivers can remove

drugs from the device?

59. Has a standardized process been devel-

oped for selecting drugs stocked in the

dispensing units relative to where these

devices are located in the facility?

59.1. Are the specific needs of individual

resident care units considered when

inventories are defined?

60. Have maximum dose ranges for “high

alert” medications been established, and

are these values visible on the dispensing

units as a ready reference?

61. Is the importance of removing only a

single dose (unit of use) of medication

ordered stressed to caregivers?

61.1. Are caregivers instructed to return any

unused drugs to the pharmacy as soon

as possible and not to place them back in

the ADU?

62. Is stocking and restocking of medications

in ADUs evaluated by on-site or consul-

tant pharmacy staff for accuracy?







63. Is staff competency in performing inde-

pendent checks (double checks) for all

high-alert medications—even if bar-code

bedside scanning is in place—reviewed?

64. Have nontechnical interventions, includ-

ing the following, been considered as

prevention strategies:

a. Using system analysis to identify

and mitigate risks associated with

medication use?

b. Fostering a culture of safety?

c. Improving error detection and

reporting?

d. Reconciling resident medications?

e. Improving communication among

those involved in the medication-use

process?

65. Does the facility have a medication safety

system in place that

a. provides comprehensive reference

material concerning medications and

related health data that is readily

accessible to providers?

b. communicates resident-specific

medication-related information

in an interoperable format?

(Interoperability is defined as the

ability of information to be easily

aggregated, stored, displayed in a

single view, and shared.)

c. assesses the safety of medication

use through active monitoring and

uses the monitoring data to improve

implementation of prevention strategies?

d. includes plans to implement

electronic prescribing?

e. subjects prescriptions to evidence-

based, current clinical decision-

support recommendations?

f. requires caregivers to possess

appropriate competencies for each

step of the medication-use process?





(continued



g. reviews in an ongoing process

potential drug hazards identified by

patient safety organizations?

Medication Reconciliation

66. Is there a protocol in place that requires

verification of residents’ medications

upon admission, during transfer from

one level of care to another, and at

discharge?

67. Is there an effective system in place that

facilitates communication with acute

care providers and other care providers

so that an accurate list of medications istransmitted among them as a resident

moves through different levels of care?

68. Are residents provided with an accurate

list of medications when they leave

the facility?

Standardization

69. Is the process for prescribing, preparing,

dispensing, and administering medica-

tions standardized?

70. Are the facility’s preprinted medication

order forms or computerized forms

standardized?

71. Are established dosing protocols used?

72. Are medications available in ready-to-

administer form?

73. Are dangerous abbreviations, symbols,

and drug dose designations forbidden?

74. Is medical equipment such as infusionpumps and other medication delivery

devices standardized across the facility?

Role of the Pharmacist

75. Do the facility’s policies and procedures

address the pharmacist’s role in the med-

ication process?







75.1. Is the pharmacist’s role in the medication

process consistent with state and

federal laws?

76. Does the facility’s pharmacist conduct

reviews of drug regimens on a

monthly basis?

76.1. Are drug regimens reviewed more fre-

quently than every 30 days when the

resident’s condition warrants it?

76.2. Do drug regimen reviews include an

assessment of the number of medications

and drug classes as well as potential

drug/drug interactions?

76.3. Do drug regimen reviews include anassessment for potentially inappropriate

medications for the elderly, in accordance

with the Beers* criteria and/or the Cen-

ters for Medicare & Medicaid Services

State Operations Manual?

77. Do the facility’s pharmacists

a. promote the development and use

of medication error identification,

reporting, and evaluation systems?

b. participate in the examination

and evaluation of the causes of

medication errors?

c. educate caregivers about medication

errors and methods of prevention?

d. recommend strategies for system

changes to prevent medication errors?

e. cooperate in reporting relevant

medication errors to a national

system for review, analysis, and

development of recommendations to

reduce and prevent medication errors?

Education

78. Does caregiver and leadership education

address the Joint Commission’s National

Patient Safety Goals and medication-

safety-related recommendations from

patient safety organizations?

* For a list of drugs, see: Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997 Jul 28;157(14):1531-6





(continued



79. Are educational programs developed to

heighten caregiver and provider aware-

ness of medication policies and procedures?

80. Are educational sessions provided to

caregivers when new drugs or new drug

delivery systems are introduced?

81. Do caregivers have access to drug infor-

mation regarding medications on their

units as well as information on the error

potential and safety and efficacy of these

medications?

81.1. If yes, are procedures in place to remove

outdated materials?

82. Do pharmacists provide caregivers withinformation on rarely used drugs that

have been ordered for a resident?

83. Do educators review with caregivers

through initial and ongoing education

a. the common types and causes

of medication errors, using case

studies as examples?

b. the importance of timeliness and

thorough reporting of medication

events and near misses?

c. the importance of clarifying unclear

orders?

84. Is specific education provided on safe

medication practices that target high-

alert medications such as insulin and

warfarin?

85. Are new personnel educated in the use of

the facility’s medication event reporting

system?

85.1. Are personnel provided periodicrefresher training on the facility’s event

reporting system?

86. Is medication safety information offered

to physicians or other prescribers of med-

ications to the facility’s residents?

87. Is medication safety included in resident

and family education?







88. Does the facility provide residents and/

or families written educational informa-

tion in language they can understand to

promote medication safety upon admis-sion and at discharge?

89. Does resident education include a “teach

back” component to assess the resident’s

level of understanding about medications?

Medication Event Reporting

90. Are caregivers given clear definitions of

actual and potential medication errors

and specific instructions on how to report

a medication event, a near miss, or an

unsafe situation that could lead to a med-ication error?

91. Are caregivers instructed to submit an

event report even if an error was cor-

rected before it could affect a resident?

92. Are caregivers instructed to preserve

any relevant packaging, tubing, or other

material that may be important in ana-

lyzing the cause of an error?

93. Are caregivers instructed not to specu-

late why an error occurred and to avoidrecording speculative remarks in the

resident’s chart?

94. When a medication error occurs, does

the risk manager work with caregivers to

identify how best to disclose the informa-

tion to residents and/or families?

95. Does the facility have a policy on disclo-

sure of errors or adverse events?

95.1. Do caregivers comply with this policy

when a medication error has occurred?

96. If a medication error occurs, does the facility

a. support those involved in the error

with counseling?

b. conduct a systems analysis of the

incident?

c. report the incident to appropriate

outside groups as may be required

by law?





(continued



97. When a medication error involving a

device results in death, serious illness,

or serious injury to the resident, does the

facility report the event to FDA? 98. Does the medication event reporting sys-

tem facilitate the collection of data that

allows classification of events by type of

error, step in the medication-use process,

and other event details such as location

and time of the event?

99. Is there a process in place to categorize

medication errors based on severity level?








Corrective Action Form

MEDICATION SAFETY

Assessment Completed By: Date:

QUESTIONNO. ACTION REQUIRED RESPONSIBILITY

TARGETDATE

ACTION COMPLETED

DATE INITIALS




QUESTIONNO. ACTION REQUIRED RESPONSIBILITY

TARGETDATE

ACTION COMPLETED

DATE INITIALS


Date post:	04-Jun-2018
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Sample CCRM Medication Safety SAQ

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