Medication Misadventure ESCAPE ROOM

Escape room

Medication Misadventure

Start

Just a typical workday in the pharmacy when the phone rings. Listen to the phone message and review the objectives in the folder below. Then look around the office to see what resources might help you investigate!

Mission 1: Identify potential medication misadventures

Question 1

After receiving the call from Nurse Eve what should you do?

Get details -patient M#, room, Omnicell location, time and date, and who might have information about the med misadventure

Tell her to just manually put in the barcode number from tablet and give anyway.

Mission 1: Identify medication misadventures

Question 2

Which of the following are other ways to identify medication misadventures at EMH?

Chart reviews, talking to patients, reviewing use of reversal agents or known antidotes, fielding questions

Subpoenas from lawyers, reviewing package insert, reviewing refill rates for adherence

Complete all missions to get your certificate

Mission 2

Mission 3

Mission 1

Identify potential medication event

Investigate/ gather information

Evaluate contributing factors

Mission 4

Mission 5

Mission 6

Categorize event

Take action

Report event

Mission 2: Investigate

Question 3

What information will be most helpful in investigating this error?

Look at the remaining tablets in the metoprolol bin of Omnicell

Look at the patient's blood pressure

Look to see if Nurse Eve has made errors before

Mission 2 : Investigate

Question 4

You find that there are 2 other metoclopromide tablets still in the metoprolol bin of the CVU omnicell. What is your next best move?

Check to see if the metoclopromide tablets will scan correctly

Pull them and check if the central pharmacy metoprolol bin contains any metoclopromide

Check to see if the eMAR uses tall man lettering for metoprolol

Mission 2 Investigate

Question 5

What else might you check in Central Pharmacy?

Look at metoclopramide bin for metoprolol tabs

Who the new technicians are that might have made error

Check how many metoprolol were purchased

Mission 2: Gather information

Question 6

What Omnicell information should you start to gather for investigation of this event?

MISSION 2: INVESTIGATE

Question 7 Besides action taken with Omnicell, what should you do to prevent this error in the future?

Check Nurse Eve's scan rates

Post the error and names involved on the bulletin board

Share the event details (no names) and what action was taken at todays PHA safety huddle

Advise Director to counsel the technician who made the error

Mission 3: Classify contributing factors

Question 8

Which of the following is a contributing factor in this event?

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Barcode labeling error

Equipment error (scanner)

Human factors

Complete all missions to get your certificate

Mission 2

Mission 3

Mission 1

Investigate

Classify contributing factors

Identify error

Mission 4

Mission 5

Mission 6

Categorize

Report

Take action

Mission 3: Classify Contributing Factors

Question 9: Put in the correct order for classifying a medication error. Check the key before continuing.

a-Report error in QStatim

b-Identify contributing factors

c-Invite others to evaluate event

Continue

Solution

Click on each icon below for Investigation Tips

Mission 3: Classify contributing factors

Question 10

Which is often a contributing factor with medication misadventures?

Utilities failure

Adherence to policies and procedures

Failure to follow P&P or safeguards

Complete all missions to get your certificate

Mission 2

Mission 3

Mission 1

Investigate

Classify contributing factors

Identify error

Mission 4

Mission 5

Mission 6

Categorize

Report

Take action

Mission 4 : Categorize

Questin 11: Drag concepts to the corresponding group

Reportable med event

Non-reportable med event

IV line infiltration

Near miss

Side effect

Adverse drug reaction

Medication error

Continue

Solution

Complete all missions to get your certificate

Mission 2

Mission 3

Mission 1

Investigate

Classify contributing factors

Identify error

Mission 4

Mission 5

Mission 6

Categorize

Report

Take action

Mission 5 :Report

Question 12

How are medication errors reported at EMH?

Paper report forms submitted to Director of Pharmacy

Qstatim electronic reporting on EMH intranet

Find the correct 3 icons to report medication misadventures in Qstatim

Mission 5 REPORT

Question 13

Place in correct order to start Qstatim report on medication error.

A) Click on Qstatim icon/link

B) Click on Medication bottle icon

C) Go to EMH Intranet

D) Select hospital/location

Continue

Solution

Mission 5 :Report

Question 14

What medication misadventure type events are reportable in Qstatim?

Medication errors that reach the patient, Side effects, refused medications

Medication events, IV line events, Adverse dug reactions and near misses

Sorry!

TRY AGAIN

Mission 5 :Report

Question 15

What medication misadventure type events are reported externally?

Medication errors that may lead to lawsuits due to negligence

Adverse dug reactions involving vaccines or novel unreported reactions

Mission 5: Report

Question 16: Drag concepts to the corresponding group

Required information to report in Qstatim

Not required for Qstatim report

Reporter name

Patient name & Med Rec#

Associate making error

Date & time of event

Associates involved

Continue

Solution

Mission 5 : Report

Question 17

After a medication error is reported how is the information shared?

Medication errors are submitted to the Doctor to share with patient

Monthly aggregate reports go to Safety/Quality Committee, P&T and Med Safety teams

Medication errors are shared with Directors to put in Associate file

Complete all missions to get your certificate

Mission 2

Mission 3

Mission 1

Investigate

Classify contributing factors

Identify

Mission 4

Mission 5

Mission 6

Report

Categorize

Take Action

Mission 6 :Take Action

Question 18

Which of the following are NOT appropriate action options after a medication misadventure is reported?

Post error report on bulletin board with Associate name involved

Make change to drug dictionary comments in Meditech

Educate staff on real and potential errors from ISMP newsletters

Provide inservice for staff on correct procedure to mitigate risk of error

Mission 6 Take Action

Question 19

Which EMH Pharmacy policy helps guide reporting and action taken in response to a medication error ?

EMH PHA 031 Medication Occurrence Reporting

EMH SW 107 Management of Adverse and Sentinel Events

EMH SWH PC 031 Adverse Drug Reaction Reporting

Congratulations!! You have completed all missions

Mission 2

Mission 3

Mission 1

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Mission 4

Mission 5

Mission 6

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ESCAPE THE MEDICATION MISADVENTURE LOCKS NOW!

Now it is time to solve two puzzles to unlock and ESCAPE! Find the hidden LOCK icon in the office. HINT: Everything you need to know is in the residency office "room where it happens"- click on the KEY icon below to go back

To escape this medication misadventure find the LOCK and solve two puzzles. Everything you need to solve the puzzles are in this room. HINT: Look in new places for more clues . YOU TOO can be a sleuth and solve the mystery.

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