...AFT2 Task 3 / Tracer Patient A.1. Evaluation In reviewing the Surgical Patient Tracer Worksheet (SPTW), it was found that a deficiency was noted that stated “History and physical not done within 24 hours of admission (> 72 hours).” This meant that the laparoscopic hysterectomy related History and Physical (H&P) the patient received was used for the abdominal hysterectomy. Plus, it was more than seventy-two hours after being admitted to NCH for surgery that the patient received the H&P for the abdominal hysterectomy. In reviewing the Tracer document and other information, it became clear that there were three violations of Joint Commission Standards (JCS) for PC.01.02.03 which states: “The hospital assesses and reassesses the patient and his or her condition according to defined time frames.” (Joint Commission, 2014 August). The violations are as follows: 1) When bleeding was detected, the doctor made the determination that the less invasive laparoscopic hysterectomy the patient was scheduled to undergo would need to be changed to an abdominal hysterectomy. The tracer shows no evidence that neither the doctor nor anyone else associated with the surgery including the Anesthesiologist asked for a new H&P to determine the possible complications the bleeding might have on the choice of surgical procedure. The violation relates to JCS PC.01.02.03 Element of Performance (EP) 3 which states: “Each patient is reassessed as necessary based on his or her plan for care...
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...ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS 1 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...
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...that occur earlier in the medication process are more readily detected (~50% are prevented during the ordering stage) while very few (< 2%) are caught at the administration stage (bates et al., 1995). further, it has been noted that more than one third of medication errors occur at the latter stage (leape et al., 1995). because of the relatively high proportion of errors and the lack of success preventing them, error reduction strategies targeted at the administration stage High rates of preventable medication errors have been repeatedly reported in studies in the medical literature (Bates et al., 1995; Leape et al., 1995; Flynn et al., 2002; Kanjanarat et al., 2003). It is difficult, however, to cite a single number to define the extent of the medication error problem due to differences in institutions, study methodologies, error definitions, and other variables. On the high end of estimates, one study that compiled data from 36 institutions reported 19% (~1 in 5) of the medication doses studied over a 4-day period involved medication errors (Barker et al., 2002). These errors included wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). The number of these errors deemed potentially harmful adverse drug events (ADEs) was 7%. A comprehensive review of medication error studies cited in the Institute of Medicine (IOM) 2000 report on errors in the U.S. healthcare system suggests that preventable ADEs, i.e., harmful medication errors, occur in ~1% to 10%...
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...Furthermore, leadership in a hospital or inpatient setting is crucial that could affect the turnover, job satisfaction, performance and most importantly the services provided by the nurses which may affect patient outcomes and patient safety. In this essay, it will discuss different leadership styles such as autocratic, bureaucratic and democratic leadership style and its’ relationship to the safety of patient specifically the factors in medication errors in an inpatient setting. According...
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...Implementing Barcode Medication Administration in Hospitals Part Three Creating Change in Organizations/HCS587 April 1, 2013 Dr. Sonnia Oliva Change needs to be evaluated after implementation to determine its effectiveness. The organization and management need to continually monitor BCMA to make sure the organization is benefiting from it and to modify components if necessary. Outcome measurement strategies for BCMA are not conclusive but single studies show its positive impact on patient safety. Additionally, cost, quality, and staff satisfaction are important when determining the effectiveness of BCMA and they all support the use of BCMA as technology that increases patient safety. Effectiveness of Organizational Change Organizations evaluate the effectiveness of change after it is implemented to determine if the change is valuable or costly. Effectiveness of BCMA also needs to be determined to ascertain its ability to increase patient safety by decreasing medication errors. Empirical data on BCMA’s effectiveness is limited and data is also inconclusive. Although, data collection conducted by the Veteran Health Administration (VHA) was used to offer suggestions for improved effectiveness. From 1999 to 2003 data was collected by VHA on the barriers that was making BCMA less effective. Laboratory use, nursing informatics, and interviews were used to determine suggestions VHA would recommend to improve BCMA’s effectiveness. The data was given to the VHA’s...
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...recovering from an acute situation or services needed by clients with ongoing chronic conditions. The skills and duties of home health nurses vary, but all have one thing in common and that is to make it possible for clients to remain at home and in some cases, have more independence and control. In the process, home health also provides caregivers and clients with a chance to participate in the plan of care. Inpatient Care versus Home Healthcare The main difference between receiving care through home health and a traditional inpatient care is the location. Traditional inpatient care is done in the confines and security of the hospital while home healthcare is done in the comfort of the client’s home setting. Inpatient nurses can provide round the clock care and have the advantage of being acquainted with the client’s overall acuity; nursing care is based by importance of nursing diagnoses. While adapting to the patient’s home setting, home health nurses must provide care by adjusting to the client’s routine. Home health nurses work alone in the field with support resources available from a central office (Ellenbecker, Samia, Cushman, & Alster, 2007, p. 301). In an inpatient setting, care is usually provided by nurses and other practitioners whereas with home health, family members and aids are trained regarding the client’s health maintenance. Collaborative Roles of the Home Healthcare Team Depending on the agency and its location, the home healthcare team may include a...
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...Traumatic Brain Injury WUT2 Task Western Governors University A. Investigated Disease Process The disease process I will be reviewing is traumatic brain injuries. A traumatic brain injury occurs when sudden trauma occurs to an individual’s brain. Traumatic brain injuries are considered closed or penetrating. Traumatic brain injuries are categorized as mild, moderate or severe based on the amount of damage that occurs to the brain. (ninds.nih.gov, 2015) A1. Pathophysiology To understand traumatic brain injuries, we must first discuss the numerous causes of brain injury. When injury occurs to the brain, the patient encounters the primary injury that is directly related and occurs at the time of the injury. Secondary injury occurs as a result of the primary injury but often leads to a more significant sequela based on the type of initial trauma. Non penetrating injuries to the cranium that lead to traumatic brain injuries are not always related to direct blows of the cranium. Rapid acceleration and deceleration injuries along with compression injuries may lead to traumatic brain injuries. This type of injuries can lead to injuries to the brain tissue that could include compression, stretching and shearing injuries to the brain tissue. These type of injuries are classified as “diffuse axonal injuries”. Diffuse axonal injuries are one of the most common and extensive types of traumatic brain injuries. These injuries often lead to death or severe irreversible...
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...Substance Abuse Amy L. Teoli HCA/250 December 21, 2014 George Decker Substance Abuse Addiction is a complicated disease that affects the behavior and functions of the brain. It occurs when a person becomes dependent on a drug or medication. This could include legal and illegal drugs, prescription drugs, and alcohol. Substance abuse not only affects individuals, it also affects their friends, family, and other people around them. In 2012, there was an estimated 23.1 million Americans aged 12 and older who needed treatment for substance abuse (SAMHSA, 2014). Educating ourselves and others on preventing and treating substance abuse disorders is important because it can affect a person’s physical and mental health. Substance abuse can affect anyone. Some people can be functioning addicts, meaning one would never knew they had a problem. Others have trouble keeping a job, forming romantic relationships, they become needy, and withdrawal from their family and friends. Physical dependence is when the body becomes adjusted to a substance, and needs that substance to function normally. Psychological dependence is when a person uses a substance to feel the effect it produces, but their body is not dependent on it. An individual may have biological and psychological characteristics that make them vulnerable to substance abuse. Biological characteristics include genes, gender, and ethnicity. Scientists estimate that genetic factors account for about 40-60...
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... b. Voluntary i. Patients who access treatment voluntarily by consenting to be admitted and treated. c. involuntary/emergency ii. When the effects of the patient’s mental illness result in an immediate risk of self-harm or harm to others, or the effect of the mental illness is such that the patient is unable to provide food, clothing, or shelter for him/herself, and emergency commitment is appropriate. 1. Short period and more restrictive criteria for admission. 2. State requires that a mental health official see the individual. 3. A 2nd mental health professional makes and examination once the individual is brought to the inpatient unit. 4. Probable cause hearing must take place to continue the hospitalization. d. civil/judicial iii. Longer amount of time than emergency...
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...may include misuse of service which is generally preceded at onset by prior unacceptable level of errors. The purpose of this paper is to highlight medication errors as a health care safety issue. One solution involving automation would be explored since it has long been recognized as an important factor in reducing human errors in work processes. It is crucial to showcase this because numerous studies have substantiated the positive effects of health IT on quality and safety improvements, Slovenky & Menachemi (2011). A safety Initiative With new tools provided by the Affordable Care Act, hospitals can now aggressively implement programs with sole aim of assisting in the reduction of preventable errors. The act provides hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals, to support their efforts to reduce harm, McKinney & Zigmond (2011). The government predicted that this could save 60,000 lives over the next three years and potentially save up to $50 billion in Medicare bill. The federal government is encouraging providers to adopt and effectively use electronic health record (EHR) systems, Heubusch (2011). The goal in the development and use of EHR’s is to enable effective and measurable improvements in the health of individuals and fully involve them in the process....
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...those in the community that THR provides healthcare services to. The electronic health record is shared amongst the healthcare team and other affiliates. Data collection can be continuously updated, used for “statistical evaluation for purposes of quality improvement, outcome reporting, resource management, and public health surveillance.”(Yamada, 2008, p. 5). Data collection is generally initiated in the ER, and other times when the patient is at the physician's office or in the outpatient service line. To reference inpatient services, data collection begins in the ER. The patient's allergies, current medications, medical history, vital signs, immunizations, suicide screening and domestic violence screening are all obtained upon the patient's arrival to the ER. The gathering of this information, initiates a process for interdisciplinary data collection. All healthcare team members can access a patient’s previous visits whether it is outpatient, inpatient, diagnostic or office visit. Labs and radiological tests are shown by date and time and are listed in chronological order. The clinical staff member...
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...Improving The Safety Of Using Medications In Hospital Settings Background Improving the safety of using medications was the third Joint Commission safety goal for 2014 (Hospital National Patient Safety Goals, n.d.). Every year medication errors are a significant cause of morbidity and mortality in hospitals. Simply put, medication errors come from incorrect dosing by physicians on prescriptions, administration of the wrong dose of the prescribed medication to the patient, failure of the healthcare provider to administer prescribed medication, or failure of the patient to ingest said prescribed medication (Choo, J., Hutchinson, A., & Bucknall, T., 2010). Role of the Nurse According to the Journal of Nursing Management, nurses should practice the five rights of administration that they are taught while in school. Those rights are: right medication, right dose, right route, right time, and right patient (Choo, J., Hutchinson, A., & Bucknall, T., 2010). While checking the five rights is useful in the final stages of the administration process, the rights do not reflect the other complex steps to medication administration, such as preparation, labeling, determining interaction, etc. Normally medication errors are never the result of an isolated human error. They may come from workplace stress, distractions, interruptions, insufficient training, and misinformation (Choo, J., Hutchinson, A., & Bucknall, T., 2010). The individual nurse should make sure that...
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...REDUCING FALLS IN THE HOSPITAL SETTING Abstract “Falls and fall related injuries are the most commonly reported adverse event among adults admitted to inpatient setting. Up to twenty percentages of patients admitted, reported falling of at least once during an inpatient hospital stay period” (Oliver, Healey, & Haines, 2010). The author works at a city hospital located in Gilbert, Arizona and encounters a great amount of orthopedic patients along with other general surgery patients. All patients that are on that floor are at a risk of falls during the first 48 hours after surgery due to anesthesia that is still in the system and pain medication that is scheduled to help ease the patient during the post-surgical time frame. One of the side effects of anesthesia exiting the body is nausea and vomiting which can make the patient feel dizzy and lightheaded, thus making them a great risk for falls. This has been the reason that the topic was chosen; to attempt to improve this issue in the hospital setting and to provide a system in which all hospital staff collaborate to help increase the quality of patient care. The location that is being observed is the post-surgical/orthopedic floor where the author is currently working. A description of risks and concerns are provided and patient outcomes depend on implementing the proposed interventions. The two solutions that are presented are hourly rounding and the importance of an improved nurse call light button and education on proper...
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...Prevention of Medication Errors in Nursing Practice Breton Sloop NU 332 Foundations of Nursing November 11, 2015 Teresa Faust Mary is a critical care nurse at a busy urban hospital, who is trying to catch up on her morning medication administrations. Her patient had required several procedures that morning, due to an alteration in his condition, and now Mary is behind schedule. The patient is intubated, so she decides to crush the pills, and administer them through his nasogastric tube. The patient’s medication is already late, but in her dash to give the medication as quickly as possible, she fails to notice the “Do Not Crush” warning on the electronic medication administration record (MAR). She then crushes an extended-release calcium...
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...information from the case we will attempt to address some explanations to the issue of medication errors being dispensed at HMO pharmacy. A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality shows the categories of dispensing errors. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the pharmacist, this list can be extended by the addition of three other categories: failure to detect and correct a prescribing error before dispensing; failure to detect a manufacturing error before dispensing; and failure to provide adequate patient counseling in order to prevent administration errors. These categories arise in other segments of the pharmaceutical patient care chain, but they are nevertheless important when one strives for a full assessment of the pharmacy's performance. (a-Chun Cheung, Marcel L Bouvy, and Peter A G M De Smet) I am going to attempt a process map to the best of my ability on filling process for HMO’s pharmacy, in which some key problems that the HMO’s pharmacy might be experiencing. A SIPOC diagram is a tool used by a team to identify all relevant elements of a process improvement project before work begins. It helps define a complex project that may...
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