...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 to occur in the emergency room, operating room and critical care units (IOM, 1999; Rogers, Dean, Hwang & Scott, 2008). The purpose of this paper is to address the serious problem of medical errors in healthcare in general and specifically the techniques critical care nurses employ to identify, correct and/or interrupt such problems (Henneman, Gawlinski, Blank, Hennema, Jordan & McKenzie,...
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...In the 1999 research studies began to review the problem of medical errors and how they occurred. Studies and reports, such as the Institute of Medicine IOM report in 1999, strongly suggest that most medical errors are related to systems and processes and not individual negligence or misconduct. The IOM report recommended that the key to addressing medical errors is to focus on improving the processes used to deliver healthcare and not placing blame on the individuals involved. Approximately 1.3 million people are injured annually in the United States following "medication errors". The FDA defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or harm to a patient”. The U.S. Food and Drug Administration (FDA) currently review medication error reports that come from drug manufacturers and through Med Watch, the agency's safety information and adverse event reporting program. The agency also receives reports about medication errors from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia. Some things the FDA has put into place to prevent medication errors: * Drug Name Review: To minimize drug name confusion, FDA reviews about 400 drug names a year that companies submit as proposed brand names. The agency rejects about one-third of the names that drug companies propose. * Drug Labels: FDA regulations require all over-the-counter (OTC) drug products (more than 100,000) to have a standardized...
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...and Patient Safety Assignment” Nurses inherently are concerned with patient safety. They are best positioned to prevent medical errors at the bedside. There is a moral and legal imperative to implement safe practices at all times. Nurses and the profession are negatively impacted when medical errors occur. Until recently the Centers for Medicare & Medicaid Services (CMS) mandated that all patient medications be administered 30 minutes before or after a scheduled time (Department of Health & Human Services [DHHS] & Centers for Medicare & Medicaid Services [CMS], 2011, December 22). Given the expanding role of nurses, the CMS mandate is now unrealistic and counter-productive. The Institute for Safe Medication Practices (ISMP) addressed this issue by creating an Acute Care Guideline for the timely administration of schedule medications. Institute for Safe Medical Practice The ISMP is dedicated to preventing medical errors by promoting safe medication administration procedures (ISMP, 2013a). The ISMP reviews all facets of safe medication administration. Medication errors frequently result in debilitating injuries or death. The ISMP posits that the most frequent medical error is medication administration. Medication error affects over 1.5 million people annually (ISMP, 2007b, p. 1). The ISMP has committed staff and resources to reduce medication errors. It has developed training and educational programs for health care staff and consumers. “30-minute rule” Challenged ...
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...1. Critical analysis of an issue in the clinical area a) My topic is Medication Error. b) I choose this topic because during my experiences in clinical area as well my experience in Hospital 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...
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...html Errors 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...
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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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...Why Are There So Many Deaths Caused By Medical Errors and What Solutions Can Decrease Them? Health Service Systems – HSM541 June 20 2015 Background Medical errors kill at least 44,000 people and perhaps as many as 98,000 people per year. Or do they kill over 180,000 per year? Maybe even 440,000 people killed by medical errors? Allen (2013) In 1999 the Institute of Medicine (IOM) published a report titled “To Err Is Human: Building A Safer Health System” that leveled the healthcare community. They reported that according to two studies “perhaps as many as 98,000 people die in hospitals each year as a result of medical errors that could have been prevented”. IOM (1999) Then the Office of Inspector General for Health and Human Services followed up with a report in 2010 that stated “bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year”. Allen (2013) And finally in 2013, the numbers were once again raised. Per a report from the Journal of Patient Safety that approximately “440,000 PAEs (preventable/potential adverse events) that contribute to the death of patients each year from care in hospitals. This is roughly one-sixth of all deaths that occur in the United States each year”. They are now the U.S.’s third leading cause of death, behind only heart disease and cancer. All of the numbers mentioned in the first paragraph are medical errors that were “preventable”. Mistakes by the people you put your trust in killed you...
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...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...
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...who are far from happy about the level of care they received while sick. Quality problems are present in wide variation across board when talking delivery of health care services, in some instance, the issue could be with underutilization of a particular service, and other instances 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...
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...From Medscape Nurses Medication Error Prevention for Healthcare Providers Faculty and Disclosures CE Information There are between 44,000 and 98,000 individuals who die every year in hospitals due to preventable medical errors.[1] It has also been reported that this is only part of the problem, as thousands of other patients are adversely affected by medical errors or barely avoid injuries that are nonfatal.[2] These medical errors not only cost the loss of lives, but carry a financial burden that is estimated to be in a range of $17 billion to $29 billion annually. Additionally, there is physical and psychological pain and suffering related to these errors.[1] Another consequence is that medical errors diminish trust and satisfaction in the healthcare system and in healthcare professionals.[1] Ginette A. Pepper, PhD, RN, FAAN, a Professor and Helen Lowe Bamberger Colby Presidential Endowed Chair and Associate Dean for Research, University of Utah College of Nursing, Salt Lake City, spoke on medication safety for the geriatric nurse practitioner (GNP).[3] Dr. Pepper was trained as a pharmacologist with a nursing focus. She was one of the first NPs to add "geriatric" to her title as well as one of the first NPs to have prescriptive authority. Safety Principles and the Medication Use Process Dr. Pepper noted that safety issues are of the utmost importance for all healthcare providers.[3] Nursing as a profession has a long history of regarding patient safety as a primary...
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...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 THREATS • Cost of implementing the systems • Must be committed to the CPOE Market • Product maturity – time vendor has been developing CPOE products • Ability to measure hospital efficiency through CPOE data Executive Summary Computerized Physician order Entry (CPOE) will help to reduce medical errors and any adverse drug issue and that would improve the quality of care. We...
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...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 study on the frequency and causes of medical errors. She observed that many people were initially reluctant to believe that errors might be a significant problem...
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...Increasing Nursing Compliance with Safe Medication Preparation and Administration Marie Shelly Capstone Course Increasing Nursing Compliance with Safe Medication Preparation and Administration The importance of safe medication preparation and administration in healthcare settings is being increasingly recognized. There have been numerous publications describing the transmission of bloodborne pathogens, viruses, and bacteria related to unsafe injection practices. The current field of nursing requires concerned parties to exercise a critical appraisal of research findings, and, establish a synthesis of contextual and empirical evidence that is relevant. However, practitioners have not established better alternatives regarding their practice. In addition, the essential evidence-based methods and critical skills in thinking are still lacking; yet they are ideal for the maximization of the cost-effectiveness and quality of health care (Camiletti, & Huffman, 1998). The Center for Disease Control reported that between 1998 and 2008 a total of 33 outbreaks of patient to patient transmission of HBV or HCV due to breaches of infection control by health care personal (http://www.cdc.gov/injectionsafety/CDCsRole.html1). More than 60,000 patients were at risk and 448 patients acquired with HBV or HCV. The disease transmission was primarily from lapses in aseptic technique, the reuse of syringes and contamination of medications that were multi-dose vials. In 2001(Luby, 2001) The World...
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...find a way to function through the day with a Seeing Eye dog or reading with Braille knowledge, and if a person is unable to hear they are able to function at a very high level through the use of sign language and reading lips. Communication in the healthcare field may be a little different for some people. Healthcare requires the communication to have a purpose, and that purpose is revolved around a person’s needs. A patient with good staff communication during his or her care will have a positive outcome, get well, and be discharged faster. A new breakthrough in healthcare is telemedicine where remote geographical locations will have access to specialty health services with the help of state of the art medical equipment. A patients vital signs and electronic medical record, any questions or concerns can be transmitted to a doctor miles away for his or her opinion on the care needed. Again excellent communication between all providers involved with this patient is critical. “Taking a team approach can make real difference to your experience of work in the social care sector. By making use of good interpersonal communication skills you can achieve your best, why it's good to listen... and then talk” When taking care of their patients’ healthcare staff is looking for signs to tell how they feel. This communication can come in verbal or non verbal forms. It is through those complaints, facial grimaces, or even blinks that they can access the situation and report back to...
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...Accreditation Audit AFT Task 1 Roland Helmuth Western Governors University Accreditation Audit AFT Task 1 Medication Management A. Compliance Status I will be reviewing three specific areas dealing with medication management. They are the following with the correlating Joint Commission Standard following each one: 1. The hospital plans its medication management process, (MM.01.01.01). 2. Label all medications, medication containers, or other solutions on and off the sterile field, (NPSG.03.04.01). 3. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy, (NPSG.03.05.01). In review of standard MM.01.01.01, I see that Nightingale Community Hospital (NCH) has a policy that speaks directly to this standard. The elements of performance are met by the policy that is in place and includes further information to make this important standard compliant with Joint Commission standards. In review of standard NPSG.03.04.01, I do not find the NCH has a policy that addresses this. Seeing that NCH has surgical and sterile procedures performed at its facility this standard needs to have a policy in place. The basis of this is patient safety related to the five rights of medication administration; Right patient, Right medication, Right dose, Right route and Right time. Even in a controlled environment of a surgical suite, this is vital to any procedure performed. In review of...
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