...Patient Safety Workshop Learning From Error PATIENT SAFETY WORKSHOP LEARNING FROM ERROR WHO Library Cataloguing-in-Publication Data Patient safety workshop: learning from error. Includes CD-ROM 1.Patient care - standards. 2.Medical errors - standards. 3.Patient rights. 4.Health facilities - standards. 5.Health Management and Planning. I.World Health Organization. ISBN 978 92 4 159902 3 (NLM Classification: WX 167) This publication is a reprint of material originally distributed as WHO/IER/PSP/2008.09. © World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies...
Words: 9127 - Pages: 37
...important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The standards set expectations for organization performance that are reasonable, achievable and rational. Each standard is developed with input from healthcare professionals, providers, employers, consumers, and government agencies like the Centers for Medicare & Medicaid Services. New standards are added only if they are in relation to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured. The National Patient Safety Goals (NPSGs) have become a critical vocal point by which The Joint Commission promotes and enforces major changes in patient safety and quality of care. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness (AHRQ, 2013). Recent changes have focused on preventing hospital-acquired infections and medication errors, in addition to existing goals promoting surgical safety, correct patient identification, communication between staff, and identifying patients at risk for suicide. The most recent update in 2014 added improving the safety of hospital alarm systems as an NPSG. The purpose of the National Hospital Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how...
Words: 1209 - Pages: 5
...Practice Standard – Safety and Quality Patient safety is a high-priority issue for all professionals including pharmacists. Patient safety is defined as ‘the prevention of harm to patients, including through errors of commission and omission’. The role of pharmacists has been clinically proven to improve many outcomes regarding patient health, including greater patient safety, improved disease and drug therapy management, effective healthcare spending, improved adherence and improved quality of life (Canadian Pharmacists Association, 2008). The focus on patient care stemmed from a 1999 US report by the institute of Medicine titled, ‘To Err is Human: Building a safer Health System’. This report detailed the costs of medical errors to the US economy and how medical errors numbered higher than deaths due to AIDS, motor vehicle accidents, and breast cancer, combined. The report went on to descried how errors can be reduced (Institute of Medicine,1999). For centuries, pharmacists have been the guardians/safeguards against "poisons" those substances which could cause harm to the public. Now more than ever pharmacists are charged with the responsibility to ensure that when a patient receives a medicine, it will not cause harm. As highlighted in a report produced in November 2009 "Pharmacy Intervention in the Medication-use Process - the role of pharmacists in improving patient safety", the involvement of pharmacists in patient safety can be as early at the prescribing phase and...
Words: 1018 - Pages: 5
...Applying Theory to a Practice Problem: Part 1: Introduction and Problem of Practice Grand Canyon University Theoretical Foundations for Nursing Roles and Practice NUR-502 Jennifer Wood, BSN, MSN, PhD. January 1, 2015 Applying Theory to a Practice Problem: Part 1: Introduction and Problem of Practice Theory serves as the foundation for understanding the essence of nursing and it gives the nurse the opportunity to understand the reason for the occurrence of an event (McEwen & Willis, 2014, p. 413). In different clinical settings, nurses care for patients amidst all the interruption and distraction and therefore are prone to making medical errors despite their best intentions. Medical errors are common in most healthcare settings and more so in the critical care units. According to the 1999 Institute of Medicine (IOM) report, several thousand people die each year from avoidable medical errors. Medical errors have been defined in different ways by various authors but one that captures the essence of this problem is that contained in the IOM report of 1999 which described this issue as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (IOM, 1999). Medical errors include but are not limited to medication errors, errors associated with medical and surgical procedures, those associated with transcription and charting activities, adverse drug events, restraint-related injuries, or mistaken identities and are more likely...
Words: 1875 - Pages: 8
...Wrong-time Medication Administration Errors NUR 45200 Quality and Safety for Professional Nursing Practice May 1st, 2016. Patient Safety/Quality Improvement Statement and Chosen Cause that will Drive Improvement Wrong-time medication administration error has been identified as one of the major components of medication errors committed my health care professionals especially nurses. Several factors or causes are responsible for this error, but nursing factor will be discussed in this essay focusing majorly on medications pass time insufficiency and med pass rule of 30 minute. Nurses are directly involved in medication administration and they can play a huge role in preventing or reducing wrong-time medication administration error. Current Knowledge of the Patient Safety Concern/Quality Improvement Issue Wrong-time medication administration error is the most common type of medication errors committed by nurses. It can simply be defined as failure to administer medications 30min before or after the due due/scheduled time. The last element of the 5 Rights -- right time -- has often been governed by the "30-minute medication rule." For as long as many nurses can remember, every hospital, unit, and nurse has passed medications by this rule, which says that a medication is "on time" if it is administered 30 minutes before or 30 minutes after the scheduled administration time (although some hospitals have policies that allow a 60-minute, rather than a 30-minute, window). Such...
Words: 1381 - Pages: 6
...hospital’s labor and delivery unit. It had not been difficult to mount support for the project. POE systems had been demonstrated to reduce error rates, and medical errors were widely recognized as a large and serious problem in health care. A landmark study published in 19911 estimated that 1.3 million injuries occurred annually in U.S. hospitals, 69% of which were at last partially due to errors in patient management. The study found that 13% of injuries resulted in patient death, ‚a rate that if extrapolated to the United States as a whole suggested that approximately 180,000 deaths a year were, at least partly, the result of injuries received during the course of care.‛2 This study also found that adverse drug events (ADEs) accounted for nearly 20% of total injuries (making them the largest injury category) and that 45% of ADEs were the result of errors. A later study at two Boston hospitals found that 6.5% of admitted patients suffered an ADE, and that 28% of these were due to errors.3 1 L.L. Leape, T. A. Brennan, et al., ‚The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II,‛ New England Journal of Medicine 324 (1991):...
Words: 5077 - Pages: 21
...October 2012 – 30 September 2013 HOSPITAL AUTHORITY HONG KONG 1 ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) ACKNOWLEDGEMENT This is the sixth Annual Report on Sentinel and Serious Untoward Events. By continuously learning from sentinel and serious untoward events and by building safe systems, processes and practices to mitigate the recurrence of such events, it demonstrates the Hospital Authority’s commitment to quality and patient safety. We would like to take this opportunity to acknowledge all frontline staff, nurses, clinicians, risk managers and executives for their immense dedication and support in improving patient safety in recent years. Without their invaluable and incessant efforts in planning and executing various improvement initiatives to enhance patient safety through risk identification and mitigation, the publication of this annual report would not have been as meaningful. Patient Safety and Risk Management Department Quality and Safety Division 2 ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) TABLE OF CONTENTS Executive Summary 4 CHAPTER 1 – Introduction 9 CHAPTER 2 – Sentinel and Serious Untoward Event Policy 11 CHAPTER 3 – Sentinel Events Reported from 1 October 2012 to 30 September 2013 13 CHAPTER 4 – Serious Untoward Events Reported from 1 October 2012 to 30 September 2013 21 CHAPTER 5 – Actions Taken and Discussion 26 CHAPTER 6 – Conclusion...
Words: 11258 - Pages: 46
...9-311-061 REV: JANUARY 31, 2011 RICHARD G. HAMERMESH F. WARREN MCFARLAN MARK KEIL ANDREW KATZ MICHAEL MORGAN DAVID LABORDE Computer rized P Provide Order Entry at Emory er y ealthcar re He I think the CPOE implementation has gone exceptionally well so far. T These CPOE sy ystems are all pretty immat ture at this po oint in time. I the system we are implem In menting, the m medication reco onciliation mod dule is awful; there are some other things that are awful, but, overall, g ; , given those lim mitations, I thin the CPOE s nk system implem mentation has gone very well g l. — Dr Bill Bornste Chief Qua Officer, E r. ein, ality Emory Health hcare1 La on the drizzly afternoo of June 11, 2009, Dr. Bil Bornstein, Chief Quality Officer of E ate on , ll y Emory 2 in Atl Healthcare lanta, reflecte on the pro ed ogress of the computerize provider o ed order entry sy ystem ntation. (CPOE)3 implemen mory Healthcare’s CPOE p project, a vital cog in a $50 million elect 0 tronic medica record initi al iative, Em began in 2007. Tw years late CPOE we “live” at Emory Univ n wo er, ent versity Orthop paedics and Spine Hospi ital, Emory University Ho U ospital, and W Wesley Woods Hospital i a staged r in rollout.4 Whil Dr. le Borns stein felt good about how t implemen d the ntation had gone thus far, as he looked ahead next m month to July 13, 2009, th fast approa he aching go-live date for Em e mory University Hospital M Midtown (EU UHM) (Exhib 1), Dr. Bornstein thou bit B ught about...
Words: 9620 - Pages: 39
...Hourly Rounds Reduces Patients’ Frequent Call Lights and Improves Safety. Christian Oyibe NURS 8103 Evidence Based Practice. Governors State University Professor Somi Nagaraj, MSN, DNP. June 5, 2013. Introduction The nurse call light is an important tool in which patients used to get the attention of nurses during hospitalization. It is one of the many means by which patients can exercise control of their health care. It is done to seek the nurses’ attention for help during inpatient hospitalization. The ideal situation is that when the patient pushes the call light, the nurse or the staff will be there to find out what assistance the patient needs. However, when these calls are made by patients, and there were delays in response time, this will in turn lead to frustration in most cases, and the patient will attempt activities that threatened their safety, thereby leading to falls and other safety issues. In most inpatient hospital or other health care facilities, call lights are made by residents or patients who need bathroom or bedpan assistance. The problem associated...
Words: 2171 - Pages: 9
...where I worked, I have came across different types of medication errors which involve patients and this could be a cause for serious problems to patients and in some cases will lead to death. It is a serious matter. Also drug error can have bad effect on nurses, both personally and professionally. C) Problems that I have identified regarding this topic ISSUE 1 In Medical ward, CRF and DM patient was advised to give injection Human Mixtard 10 units BD (10 units before breakfast and 10 units before dinner). And it was advised to give the injection 20 minutes before food. But the nurse who changes the treatment chart was mistakenly written injection Human Mixtard 10 units before breakfast and 20 units before dinner. The night dose was double. But luckily it was noticed by doctor during morning round. Otherwise nobody will recognize and will give the dose as it is. And will lead patient to a serious condition. ISSUE 2 While giving tablets through NG tube, I have noticed that some nurses throw the medication when it was difficult to pass through the tube. In this case patient will not get any effect of the prescribed medication. This a serious matter in which doctor will start new drugs daily because he will be thinking there is no response for the previous drugs. He does not know what is happening from nursing side. He will assume nurses will give medications appropriately. ISSUE 3 One patient was admitted in Medical ward, was having low sodium level in the blood. And doctor...
Words: 975 - Pages: 4
...It is zascsanecessary for nurses to stay up to date on clinical practices so that they can provide the best care possible to their patients. “The nurse assumes responsibility and accountability for individual nursing judgments and actions.”(ANA, 2001, p. 1) This paper will discuss evidence-based patient safety practices, focusing on the safety practice of: Prevention of Intravascular Catheter-Associated Infection by use of maximum sterile barrier precautions. There are pros and cons to the short-term use of central venous catheters (CVC) in the hospital. The benefit of having an intravascular catheter is that it allows you to give large volumes and high concentrations of fluids to patients. It also prevents a patient on long-term antibiotics from having multiple IV starts. However, there are also serious complications with the most common being infection.(Shonjania et al., 2001) According to AHRQ, the use of maximum sterile barrier precautions decreases the risk of catheter related infections since many catheter-related infections are caused by contamination during insertion. Maximum sterile barriers consist of sterile gowns, sterile gloves, sterile drapes, non sterile mask, and non sterile cap. Since the nurses are at the bedside to assist with CVC insertions, they are responsible for implementing the guidelines set forth by these safety practices. To do this,...
Words: 420 - Pages: 2
...The primary article for this paper is title Patients Safety Threats and Solution by McCaughan & Kaufman, the article constitutes of nursing standards for safe health care practice. “The article provides great insight of what patient safety is in the health care facility. The article explains that “Many of the harms associated with health care are preventable” (McCaughan & Kaufman 48).The articles provides statistics of accidents that could have been prevented in the healthcare facility. It also explains the importance of using safety methods such as good hygiene, using gloves, washing hands to prevent the spread of disease and contamination. It also emphasizes that “in hospital, medication errors are common” (McCaughan, & Kaufman 50). It refers to medication errors as unacceptable mistakes that can be 100% preventable. Some of the errors are related to malpractice for example, administering wrong dose, administering wrong medication etc. It is inexcusable to see this kind of faults in the health care facility as it can deteriorate one’s health or even end with an individual’s life. The article also emphasizes the importance of communication between individuals in the health care facility. As stated by the article the “Lack of communication can result in family members not receiving necessary information in a timely fashion and a lack of continuity of care from community services, both of which can have serious consequences for patient outcomes”( McCaughan & Kaufman 51). The health...
Words: 425 - Pages: 2
...PART A SWOT Analysis As Director of Information Management, I have been task to implement a new clinical information system for the pharmacy at this hospital. The hospital wants a pharmacy that will enable the physicians to have the capability of doing an automatic order through Computerized Physicians Order Entry (CPOE) in hope of reducing order delays, improving the legibility of orders, streamline operations, and ultimately improve patient safety by reducing medical errors. STRENGTH • Strong leadership and executive support • Focus on improved clinical practiced • Physician support • Leading technological hospital in the metropolitan area • Current hospital focus on patient safety • Wide-ranging: various professional groups will be impacted • Highly knowledgeable information system staff • Currently a pleasant and comfortable work environment for staff WEAKNESSES • Rising cost of resources • Limited budget constraints due to previous commitments • Lack of time for user training • New technology and staff attitude towards changes • Physician and clinical staff level of comfort with technology • Some hospitals already have CPOE OPPORTUNITIES • Desire to significantly reduce medication errors • Interest in standardizing medication ordering processes • Concerns of adequate training and assistance available for all involved clinical staff • Need for improved workflow processes in pharmacy services • Must have a positive impact on hospital efficiency ...
Words: 2661 - Pages: 11
...elaborate explanation on managing change. Julie Morath, who was the chief operating officer at the children’s Hospital brought in administration change in the hospital after an incident of medical errors on a patient. Patient safety became her priority. Morath attended some training that gave her a lot of impetus and skills to bring out effective management in the children’s hospital. This brought change and improved the performance of the hospital. Morath started by putting a core team of personnel in place to help in designing and launching the patient safety initiative. She took charge in the hospital and by August 1999, she had sought assistance of many people who were highly respected in the organization. Morath partnered with the hospital’s medical director to get his input and support so that she could make him understand her strategy for enhancing patient safety since she believed that leadership of the medical director would be very instrumental in creating support for the doctors and nurses in the children’s hospital. She then set out to accomplish major tasks which include making presentations to hospital staff about research on medical errors, conducted focus groups to learn more on patient safety and then developed a detailed strategic plan for the patient safety initiative (Edmundson, Roberto & Tucker, 2007). Morath provided the hospital staff with evidence on the size and scope of medical problem of medical errors in USA. She presented data from Harvard medical practice...
Words: 1017 - Pages: 5
...Benefits of Technology in Medicine In APA STYLE Abstract Thousands of people die each year as a result of medication errors. Medication errors can be attributed to faults in both humans and medication use systems. Therefore, it is necessary to address resolutions to both of these predicaments. The anticoagulant heparin is amongst the most implicated medications. Thus, it has been documented in the top five high-alert medications. Two notable events that triggered recent interest in this topic are the heparin overdoses that occurred in California, associated with actor Dennis Quaid’s newborn twins, and those affecting neonates in an Indiana hospital. The Failure Mode Effect Analysis (FMEA) is a proactive approach to error prevention. Implementation of an FMEA system would serve as a crucial method that will help to recognize potential failures of a product or process before adverse events occur. FMEA can help identify where the use of technology can be implemented to facilitate the reduction of medication errors, especially pertaining to heparin as in this case. Studies have shown how technology, such as computerized heparin nomagram system (HepCare), smart pump infusion technology, computerized physician order entry (CPOE), and the bar coding system, can reduce medication errors. Expanding nationwide awareness of these methods should result in a significant decline of medication errors...
Words: 3378 - Pages: 14
