...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...
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...Deysi Serrano Outline: Patient Safety in Hospitals Chamberlain College of Nursing Outline: Patient Safety and Medical Errors General Purpose: To inform nurses and the general public about programs and policies in place to further decline the rates in medial errors and keep patients safe. Specific Purpose: To provide examples of why implementing proper procedures and having an open communication within the staff can prevent minor medical incidents and potential fatal medical accidents from happening. I. Introduction A. Attention Getter: Present the story of Josie King, a two-year-old girl who died because of a medical error at a renowned hospital. B. Thesis Statement: Extensive research has shown that training programs for health care workers, policies and proven protocols and communication result in an overall decrease in medical error rates. Because implementation of protocols and standardized patient safety procedures have been shown to be effective, there is good reason to expect that by continuing these medical practices, the risk of unwanted medical errors and patient harm will be significantly reduced. II. Body A. Main Point # 1: To express how medical staff and nurses in particular are the voice of concern and advocates for patients who should express open communication with both the families and doctors. 1a. Explain how break down in communication affects the quality in patient care. 2a. Describe some of the implementations hospitals...
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...Abstract Patient safety and Medical errors are one of the major concerns of healthcare industry. Our group decided to throw more light on the present situation of this issue. In this paper we have given a clear picture about the types of errors, how these errors occur and towards the end we have discussed on how to prevent these errors. The implementation of the actions to prevent errors discussed in our paper will help in improving and reducing them. In doing so, we can be leaders in an effort to provide the best care possible to all Americans. We have also discussed about the importance of patient safety. Reducing errors and improving how we respond to error is but a subset of the all-important issue of quality of care. TABLE OF CONTENTS Introduction ……………………………………………………………………………... 5 Regulatory Authority……………………………………………………………………. 5 Patient safety ……………………………………………………………………………. 6 Medical Errors ………………………………………………………………………….. 7 Why medical errors occur? .............................................................................................. 8 When errors are not reported ………………………………………………………….. 8 Types of Medical Errors ………………………………………………………………… 9 Sentinel Events ……………………………………………………………………….. 9 Diagnosis or evaluation ………………………………………………………………. 9 Medical decision-making …………………………………………………………… 10 Treatment and medication …………………………………….…………………..… 10 Dispensing ……………………………………………………………………………11 Procedural complications...
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...1. Describe one risk to patient safety that you identified and the interventions taken to ensure patient safety. One risk to safety I identified in my patient was a risk of falls. I had a patient that was very unstable on his feet and was also hooked up to an IV infusion pump. Not only was him being unstable on his feet an issue but also him pulling out the IV that was in his arm. I made sure that a bed and chair alarm was placed in this patient’s room. I also educated him on why it is important to use to call light to ask for assistance when getting out of bed. Core Competency: Caring 2. Describe one situation where you utilized advocacy resources appropriately (e.g., social worker, chain of command, interpreter) During this clinical rotation, I was able to advocate for my patient through the chain of command. I had a patient...
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...rates of other occupations, therefore they are not at an increased risk, per se, however, their overall patterns of use are unique because of the easier access to controlled substances in the professional work environment (Tanga, 2011). Patient safety is threatened by nurses who divert drugs, and therefore, these nurses become a liability to their employers. Healthcare facilities share a responsibility with nurse leaders to ensure a secure system is in place that will prevent medication...
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...Patient Safety Project Week Six Dawn Frizell NURS/588 Linda Horton University of Phoenix Patient Safety Project Week Six Executive Summary One out of five falls results in major injuries such as fractures and head trauma. Medical cost for such falls are $34 billion yearly, and hospital cost account for two-thirds of the total of falls (CDC, 2013). Along with this information, hospital losses from falls occurring as inpatients have lost millions of dollars in revenue. Many of these fall can be avoided, and can also decrease extended inpatient care along with decrease profit loss. A process must be developed here at Davis Healthcare System (DHS), in response to patient falls, injuries and profit loss. In the Mission and Vision statement at the DHS, it states several key words: high-quality care, safety, innovation, patient-centered care, and that is the reasons that we must initiate the quality improvement plan immediately. Safety deals with lack of harm to the patient and Quality is an effective, efficient and focused direction that to get to safety. Our team of experts in quality improvement will use our mission, tools, communication along with collaborating with the patients to get to the root and cause of this problem. There are several ways to accomplish this goal, 1). Purchasing an item called Radio Frequency Identification...
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...Patient Safety The patient safety issue I have chosen to discuss is hand washing in health care environments and lack of correct hand washing. The safety of all patients who attend any medical centre is the priority for everyone working in the medical field.A key patient safety issue is tackling hand hygiene and using the correct technique. According to Barbara J. Youngberg (et alt)”The association between hand hygiene of health care workers and patient safety has been recognised for over 150 years” Lack of hand hygiene and improper technique greatly increases the possible spread of infections especially the infections that are transmitted by direct contact.Direct contact is “person to person spread of infectious agents through phyisical...
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...Patient Safety The night flow team had picked up a woman in her late 60s with a history of diverticulosis presenting to the ED with bleeding from the rectum. She was scheduled for colonoscopy the next day and orders were placed for NPO (nothing by mouth) after midnight and GoLytely (bowel cleanser) to be finished within three hours before midnight. As a third year medical student, I picked up this patient the morning of her colonoscopy. She was in mild distress after a difficult night. She had not been given a bed-side commode and was told to just get up to use the restroom despite her risk for falls; the patient had debilitating arthritis, needed a walker to ambulate, and was morbidly obese Given the difficulty in physical maneuvering, she decided not to complete all of her GoLytely. In addition, she spent the night NPO without IV fluid replacement and was feeling light-headed by morning. The patient expressed her difficulties to me that morning during my pre-rounds, stating in tears how poorly she was treated and how judged she felt because of her morbid obesity. She had no intention of returning to our medical center after her current visit. The Internal Medicine (IM) team – including the attending physician, residents, and medical students including myself – addressed the patient’s concerns during rounds by apologizing for the failures of her care and advising her to get a hold of the floor supervisor in order to reach her attending physician in times of need. This...
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...The purpose of this essay is to discuss a patient safety problem and to indicate the extent of the problem along with some approaches that are utilised to address it. The problem I am going to discuss is on patient safety and infection control. The essay will be presented in three sections. What I will discuss in these 3 section are as follows, the risk factors, the most common HAI and finally how to try and prevent the spread of infection in hospital settings. First of all what is infection control? According to the World Health Organisation ‘’Infection Prevention and Control measures aim to ensure protection of those who might be vulnerable to acquiring an infection both in the general community or while receiving care during hospitalisation’’....
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...Patient Safety in a Home Care setting 1 Kimberly Casimier Chamberlain College of Nursing Instructor: Pamela Morgan September 27,2014 Patient Safety in a Home Care setting 2 Introduction Thousands of deaths are caused and could have been prevented if patient safety measures would have been taken. It is very important improve patient safety compliance to prevent things like surgeries being done on the wrong site, medication errors, health care acquired infections, falls, and diagnostic errors. Patient safety not only takes place in the hospital, doctors office, and rehab/nursing home facilities, but it also takes place in the home care setting. The Speak Up home care brochure is geared to inform that patient on what to speak up about in the home care setting and if the patient speaks up and the nurse of healthcare worker complies, more errors can be prevented. The home care brochure really gives that patient many options of questions to ask the nurse or healthcare working during their home care. It empowers that patient and hopefully helps them know what they are entitled to as a patient as far as home care, questions they should ask if they are concerned and for information purposes, and I hopefully helps the patient to not be...
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...Among Psychiatric Patients Chamberlain College of Nursing NR 101: Transitions Paper Fall Semester, 2014 Preventing Falls Among Psychiatric Patients Psychiatric Patients are mobile and they have an increase risk factor for falling. This issue has been a serious problem facing the psychiatric hospitals. Referring to the article, their main objectives were to find out the causes of fall in the psychiatric hospitals, to provide preventive measures, and to know the effectiveness of those measures. According to Hakenson, Kidd, and Plemmons (2014), many psychiatric medications are the major causes of fall among the psychiatric patients. Some of their medications cause changes in the patient vital signs which often resulting in dizziness or unstable movement, and eventually lead to fall. Some of those medications they mentioned are antipsychotics, benzodiazepines, antidepressants, anticonvulsants, beta blocker, opiates and anticholinergic. However, the nature of their sickness is another factor that can cause them to fall. When someone is mentally sick, he/she will be disoriented, lacks judgment, having sleepless night and the level of anxiety will increase. All these conditions are associated with the risk for fall. However, some of the preventives measures they could have used; are setting up a chair or bed alarm on each patient’s bed or chair to alert the staff whenever the patients wants to get up without an assistance. A safety check on all patients at frequent intervals...
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...Many of the National Patient Safety goals and aims seem obvious, but the consequences of not achieving these goals can be serious for the patients and nurses alike. It is important for nurses to follow guidance so they can increase patient safety and hospital credibility and potentially save the hospital money (Institute of Medicine, 1999). The seven goals are to identify patients correctly, improve staff communication, use medicines and alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery. The six aims are to be safe, effective, patient-centered, timely, efficient, and equitable. The aims While some of the aims specifically apply to the hospital staff, all of the aims directly affect the patients....
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...Today’s healthcare institutions and providers strive to be safe places for patients to receive care, but past data indicates it has not always been so. The Institute of Medicine determined in the late 1990’s that 44,000 to 98,000 patients die from medical mistakes each year (Wachter, 2008). This tremendous number of deaths places medical care mishaps between the fifth and eighth leading causes of deaths in the United States (Kizer, 2001). In 2002, The Joint Commission established National Patient Safety Goals (NPSG) to help accredited organizations with patient safety in specific areas. An advisory group comprised of nurses, physicians, pharmacists, risk managers, clinical engineers, and others with appropriate experience advises The Joint Commission on how to address emerging patient safety issues. This group also periodically develops and updates the goals. The goals are grouped into broad categories and for 2011-2012, cover such categories as patient identification, health care-associated infections, improving communication, medication safety, reducing falls, and risk assessment. A discussion of selected elements underlying the current NPSG such as hand washing techniques, training, and lack of communication between healthcare personnel that can lead to medication errors, to falls, and even death, plus other related factors such as staffing shortages, problems with using outdated equipment, considerations in using the electronic medical records, and compliance with statutes...
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...Patient Safety Risks Medication safety continues to be one of the most significant issues in patient safety. The increase incidence of adverse drug events makes medication safety an urgent goal and should remain high on the organization’s agenda (World Health Organization, 2008). The process of medication reconciliation identifies the most accurate and comprehensive medications list, which contains all prescription medications, herbal supplements, vaccines, vitamins, and over-the-counter medications (Barnsteiner, 2008). This is a very important part of the care transition process, in which healthcare providers come together to improve upon medication safety, as the patient goes to and from different levels of care (www.uthscsa, 2010). Medication reconciliation became a frontline matter, when the Joint Commission (JC) defined its national goals to improve a patient’s safety. The JC changed its requirements to medication reconciliation under the NPSG 03.06.01 Act, which became effective on July 1, 2011 (Steeb & Webster, 2012). Even the revised version consists only of five elements of performance instead of seventeen from the previous version. The implementation process continues to be a difficult one. Every health care provider can have a role that differs from others in the process. A general goal of medication reconciliation directed towards a patient’s safety and outcomes improvement is obtaining and maintaining the accuracy and complicity of medication information and the...
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...The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. Patient identification is a big deal in healthcare because you want to make sure every patient is getting the correct care. A person with type A blood cannot receive blood that is type B, and that is why identifying every person is important. One way we can decrease the chances of misidentifying a patient is to ask the patient to state their name. This is a productive way to identify a patient, but if you are somewhere like a long-term care facility some of the residents do switch beds and don't remember their name. Another way to identify a patient is to use their date of birth. In hospitals...
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