Term
| How many medical errors occur a day? |
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Definition
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Term
| While our systems are being made more error tolerant, the are things you can do. |
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Definition
| 1. * Be open to advice from others (learn to hear concerns, stop, understand the concern, make sure it is not relevant or is, thank them, creates safe enviroment) 2. Take your time when writing/entering an order. 3. Provide clear communication 4. Listen to others when concerns are expressed. 4. Take rules/policies seriously. (Certainly this silly requirement does not apply to me?) |
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Term
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Definition
| Legible, Complete and Unambiguous. |
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Term
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Definition
| Get information---> Prescribe---> Send Rx. to pharmacy--->Pharmacist Review--> Prepare medication--> Dispense--->Nurse Review---> Administer medication--> Monitor patient---> repeat |
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Term
| Get Drug information before Prescribing. |
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Definition
| Patient may already be on a medication that causes a side effect that will be doubly bad with the medicaiton you want to prescribe. (example Atrovastatin and voriconazole, both cause hepatotoxicity) |
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Term
| Medicaiton Reconciliation |
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Definition
| Consideration of previous medication therapy while developing or modifying therapeutic plan: What was ordered vs. what was administered (Look at medication administration record), Therapy used by previous care team in the hospital, Therapy used by patient prior to admission. |
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Term
Medicaiton Reconciliation
Transistions in Care |
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Definition
Errors can occur when a patient's care is passed from one group to the next.
Medication therapy may be inappropriately: continued, omitted changed or duplicated. |
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Term
Ordering Medicaitons
Therapeutic Plan-----> Patient Getting Better
What to do before finishing? |
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Definition
-Entering/Writing an order is a critical step (TAKE YOUR TIME)
-Proof what you type
- Read and consider alerts
-Tell a nurse when a stat order is entered/written |
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Term
Ordering Medicaitons
Incorrectly writing/entering a medication |
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Definition
-Legibility
-Name
-Dose
-Dosage form
-Frequency
-Directions
-Your signature/time/date
-Verbal Orders |
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Term
Be aware of look alike medications
Proper use of decimals |
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Definition
RIGHT WRONG
0.5 mg .5 mg
5 mg 5.0 mg
16 mg 15.6 mg
Rule: If you can't see the decimal, might an error be made? |
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Term
Dose
"Take one teaspoon of Tyelenol" |
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Definition
Could result in a 500 mg dose instead of 160 mg
Children's liquid 160mg/5ml
Infant drop 100 mg/ml (500 mg/5ml)
Adult extra strength 167 mg/5ml
-A Teaspoon contains 2.5-9.7 ml (in practice)
-Use an oral syringe or medication measuring cup/spoon (Syrinfe tips pose a choking hazard) |
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Term
You will make errors
(Make it easy for someone to know who you are and how to reach you)
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Definition
-Include your JHH identification number on all orders
-Date and time all inpatient orders
-Date all outpatient prescriptions
(Make it easy for your team members double check you work) |
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Term
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Definition
| A brand name drug is substituted for a generically equivalant alternative that is bioequivalent |
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Term
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Definition
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Term
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Definition
absorbed at same rate and same amount.
-It is established by the FDA
-Potential Problems: Sustained release drugs, Drugs with narrow therapeutic range.
-Inticating "Brand medically necessary" Medical Assistance: include reason, Insurance company may only pay for generic |
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Term
| "Unapproved" Uses of Drugs |
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Definition
Unapproved or Off- Label Use
Pharmaceutical companies may only advertise drug for FDA approved uses
Practitiioners may use drugs for unapproved uses ( Should be consistent with good medical practice)
Insurance company may not pay for off-label use of drugs |
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Term
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Definition
SPECIFIC PILL OR TREATMENT
"any procedure resulting in the improvement in the conditions of a sick person that occurs in response to treatment which is objectively without specific activity for the condition being treated" This definition hinges on the prescriber's belief involving the "Specific activity" of the treatment being used |
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Term
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Definition
RESULTS FROM THE INTERPLAY OF THE PATIENT, THE PROVIDER, THE PLACEBO AND THE ENVIROMENT. Be nice and positive with the patient results in positive outcome.
"is a neglected and berated asset to patient care. As a health care deivery systems evolve, it is imperative to recognize the value of the placebo effect so that provisions can be made for its incorporation and proper use. Any health care system that minimizes and fragments the relationship between the physician and the patient will lessen the effects of this asset." |
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Term
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Definition
| Placebo's work 1/3 of the time everytime. Chart shows numbers are all over the place. |
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Term
| CONCEPT OF REGRESSION TO THE MEAN |
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Definition
| Your well being does not reamain constant-- sometimes you feel better than average and sometimes you feel worse than average. When you are down in the dumps-- take heart--- You will feel better soon. If you try a therapy when you are down in the dumps, you are likely to feel better following the therapy regardless of the therapies effectiveness. To guard against this type of bias, it is important to use a control |
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Term
| Giving a placebo vs. doing nothing |
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Definition
-Giving a placebo is not the same as doing nothing
-Giving Narcan blocks the opiod receptors that would allow our bodies to have natural pain relief.
-Get narcan... don't get placebo effect |
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Term
| Should we ever do sham operations for the benifit of a study/ reasearch? |
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Definition
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Term
| Influence of the provider on the patient. |
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Definition
| Body language, personal bias, confidence helps signal how the patient is going to feel. Care providers can influence how well bronchodilators work. (what you tell them makes them feel better) |
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Term
| If you faith on a drug going to work |
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Definition
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Term
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Definition
Injections better than oral
Capsules better than tablets
2 more than 1
More expensive better than cheaper |
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Term
PLACE IN THERAPY
With patients consent |
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Definition
| Maybe indicated in selected cases |
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Term
PLACE IN THERAPY
Without consent |
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Definition
| Harm to the patient-provider relationship if a patient finds out they were put on a placebo. Almost never justified. Requires other to go along with the "secret/lie". |
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Term
| PLACE IN CLINICAL TRIALS (Need Informed Consent-ALWAYS) |
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Definition
A placebo in a clinical trial is ethical if: Used in healtht volunteers to differentiate drug and placebo effects.
-If a therapy has been shown to be effective in a particular illness or disease, a placebo might be considered if the value of the information outweighs the risk or discomfort to the patient. |
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Term
| Institutuional Review Board (IRB) |
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Definition
| Makes the final judgement regarding ethics as it applies to clinical research |
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Term
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Definition
is said to occur when one drug modifies the blood concentration, magnitude of effect, or duration of effect of another drug
-They can occur when a drug is added to OR removed from a therapeutic regimen. |
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Term
Types of Drug Interactions
GI Absorption |
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Definition
Decreased extent of absorption
1. Antacids reduce the % absorbed of oral digoxin, ciprofloxacin or tetracycline if it is taken at the same time
2. Cholestramine reduces the extent of digoxin absoprtion. |
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Term
Types of Drug Interactions
Distribution
PROTEIN BINDING |
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Definition
1. Highly Bound Drug Displaced by 5%
Bound 90%---> 85%
Unbound 10%--->15% (Increase of 50% of circulating drug, going to cause a problem)
2. Not highly Bound Drug- Displaced by 5%
Bound 40%---> 35%
Unbound 60%--->65% (increase of 8%) Not worried
Example: This principle can help to explain the increase in phenytoin free fraction caused by uremia and/or hypoalbuminemia and the increased free bilirubin in a an immature infant when a sulfonamide is administered |
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Term
Types of Drug Interactions
Distribution
Protein Binding
THEATIRCAL ASIDE
How do those percent changes work again? |
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Definition
-When 10 goes to 15, there is an increase of 50%
-When 15 goes to 10, there is a decreased of 33%
Absolute Difference Between The Two Numbers X 100
The Number you start with
= Percent Change |
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Term
Types of Drug Interactions
Metabolism |
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Definition
| There are many hepatic enzymes that are responsible for the metabolism of drugs. These enzymes were collectively known as P-450 enzymes. The P-450 enzymes are actually a family of enzymes. Examples of family names are: CYP1A4, CYP2C9, CYP2D6, CYP3A |
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Term
Types of drug Interactions
Metabolism
SUBSTRATE |
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Definition
When drug A is metabolized by an enzyme. Drug A is said to be a _______ of that enzyme. |
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Term
Types of Drug Interactions
Metabolism
INDUCER |
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Definition
When a drug is able to stimulate the activity of an enzyme: That drug is an _______ enzyme. |
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Term
Types of Drug Interactions
Metabolism
INHIBITOR |
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Definition
When a drug is able to inhibit (or slow) the activity of an enzyme, that drug is an inhibitor of that enzyme. |
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Term
Types of Interactions
Metabolism
*Hepatic Enzyme Induction (increase metabolism)
Increasing metabolism with Decrease half-life |
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Definition
1. Barbiturates
2. Rifampin
3. Saint Johns Wort
4. Examples: Phenobarbital: INCREASES the metabolism of warfarin (this leads to a DECREASE in warfarin effect)
Rifampin INCREASES the metabolism of oral contraceptives (this leads to a DECREASE in the effect or oral contraceptives)
St. John's Wort INCREASES the metabolism of cycloporine, protease inhibitors, others. |
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Term
Types of Drug Interactions
Metabolism
Hepatic Enzyme Inhibition (decrease metabolism)
Decreasing metabolism will Increase the half-life |
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Definition
1. Cimetidine
2. Erythromycin
3. Grapefruit Juice
Examples: Cimetidine DECREASES the metabolism of theophyline (this leads to AN INCREASE in the effect of theophylline)
Erythrimycin DECREASES the metabolism of theophyline (This leads to an INCREASE in the effect of theophyline) |
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Term
Types of Drug Interactions
Elimination
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Definition
Decreased renal secretion
1. Probenecid decreases the renal elimination of penicillin |
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Term
| Pharmacodynamic Interactions |
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Definition
Drugs with additive effects
Examples: Benzodiazepines, antihistamines and alcohol all cause drowsiness. When the two or more of these are used in combination, resulting in drowsiness is additive. |
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Term
*IMPORTANT VARIABLES*
Sequence of drugs administered
Examples Used Warfarin and Cimetidine |
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Definition
1. No apparent drug interaction problem
(A patient has been stabilized on a drug that inhibits liver enzymes e.g. cimetidine. A hepatically metabolized drug e.g. warfarin is begun and titrated into the therapuetic range.)
2. Decreased warfarin effect
( The patient described above has cimetidine dicontinued without altering the dose of warfarin)
3. Increased warfarin effect
( A patient is titrated into the therapeutic range with warfarin. Cimetidine is begun without altering the dose of warfarin) |
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Term
IMPORTANT VARIABLES
Time Course of interaction |
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Definition
1. Cimetidine inhibits hepatic enzymes within 24 hours.
2. Erythromycin inhibits hepatic enzymes slowly. When erythromycin is added to a patient taking theophylline, the theophylline level will raise in 3 to 4 days. |
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Term
IMPORTANT VARIABLES
Some interactions only occur in certain patient subsets |
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Definition
Digoxin, in 10% of the general population, undergoes significant bacterial degredation in the gut. In these patients, erthromycin will kill GI bacteria (Eubacterium lentum ) resulting in less degredation of digoxin therby allowing more digoxin to be absorbed. If a study was done on the general population, mean levels of digoxin, before and after erythromycin, may fail to show a difference. |
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Term
| Clinical Significance of Drug Reactions |
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Definition
1. A drug interaction is not necessarily a bad thing.
2. A drug interaction may cause a measureable change in a drug level without causeing measurable change in the patients clinical status.
3. The same drug interaction may be clinically important in one patient and inconsequential in another patient.
4. Personal experience cannot be relaiably used to assess the importance, or lack of importance, of a drug interaction. |
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Term
Clinical Significance
An example of variable clinical outcomes can be demonstrated by looking at the Theophyline-erythromycin interaction |
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Definition
-Erythromycin decreases the elimination of theophylline
-In a patient stabalized on theophylline, addition of erythromycin will increase the concentration of theophylline.
- Depending on the blood level of theophylline before erythromycin is begun, the level of theophyline may increase into: a sub-therapeutic range, a therapeutic range or a toxic range.
-Some patients with drug concentrations increased into the "toxic" range may not manifest signs or symptoms of toxcity and some amy become profoundly toxic. If a patient is in the "toxic" range with no signs or symptoms, the situation should be reassessed; are the dose and frequency correct, did organ function deteriorate, was there an error, is compliance an issue etc. etc. |
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