...01-96, 02-97, 10-98, 11-99, 08-00, 06-01, 06-02, 1-03, 5-03 I. Purpose To assure that all incidents not consistent with the routine operations of the hospital or the routine care of a particular patient are reported to the quality management department so that immediate attention and responses can be given to individual occurrences. Statistics can then be derived from the collective number of incidents reported and will serve as a basis for adverse patient trends, patient safety issues, or other risks and hazards to be identified, and risk reduction programs implemented. In order to promote a culture that promotes patient safety, the hospital’s Incident Reporting Policy is based upon a foundation of nonpunitive approach to incident/occurrence reporting. The hospital leadership will encourage open and honest reporting of injuries and hazards to patients, visitors and staff, this process will be nonpunitive in nature for all persons reporting incidents throughout the organization. Incidence/occurrence investigations will be viewed as an opportunity for education/process improvement, and will focus on processes and systems, rather than human error. Disciplinary action will be limited to only those employees who engage in willful or malicious misconduct, or those occurrences in which the employee failed to report an incident or hazard to patients in a timely manner. II. Responsibility A. All hospital employees...
Words: 3611 - Pages: 15
...Medication Safety Patient safety is the first priority concern for leadership in all health care organizations. The medication delivery process is the most common intervention in health care system. For that reason medication safety is considered the most challenging and complex process in improving patient care and safety during hospitalization. Medication-related errors are serious and occur at a rate of about one per patient per day (Allan, 1990). It is a harmful practice affecting patient’s health and life. Some of these errors may result in death or inefficiency of organs functions. In addition, medication errors may financially affect the health care organization due to long patient stay in the hospital for advanced treatment (Presto, 2004). This research paper will provide highlights on medication errors definition, importance of safety during medication process, factors contributing to medication errors and effective factors in preventing medication errors. Medication errors were defined as a fault in medication that may occur at any stage of the process in ordering or delivering medications (Bates, Boyle, Vliet, Scheider & Leape, 1995), either an injury occurred or the potential for injury was present (Bates et al, 1999). These errors could occur in dosing error, which is common (Lesar, Briceland & Stein, 1997), or wrong route, or wrong time, or error in medicine rate and omission error (O’Shea, 1998). Also there are some situations such as missing a dose of medication...
Words: 2061 - Pages: 9
...http://www.nap.edu/catalog/9728.html We ship printed books within 1 business day; personal PDFs are available immediately. To Err Is Human: Building a Safer Health System Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine ISBN: 0-309-51563-7, 312 pages, 6 x 9, (2000) This PDF is available from the National Academies Press at: http://www.nap.edu/catalog/9728.html Visit the National Academies Press online, the authoritative source for all books from the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine, and the National Research Council: • Download hundreds of free books in PDF • Read thousands of books online for free • Explore our innovative research tools – try the “Research Dashboard” now! • Sign up to be notified when new books are published • Purchase printed books and selected PDF files Thank you for downloading this PDF. If you have comments, questions or just want more information about the books published by the National Academies Press, you may contact our customer service department tollfree at 888-624-8373, visit us online, or send an email to feedback@nap.edu. This book plus thousands more are available at http://www.nap.edu. Copyright © National Academy of Sciences. All rights reserved. Unless otherwise indicated, all materials in this PDF File are copyrighted by the National Academy of Sciences. Distribution, posting, or copying...
Words: 104719 - Pages: 419
...to a patient as a result of medical care. An adverse event indicates that the care resulted in an undesirable clinical outcome and that an underlying disease did no cause the clinical outcome. Adverse events include medical errors, such as the use of incompatible blood products, incorrect dispensing and administration of medications. Medication errors can result in patient harm including death. Adverse events, near misses, incidents of any kind are to be reported and put in a system called Incident Response Improvement System (IRIS). All IRIS reports get reviewed by a primary reviewer and the risk manager daily. They follow up on all reports and see trends happening whether it is weekly or monthly. They are also able to compare trends from any time period they select. If trends are seen it is imperative to follow up with staff to find out why there is a rise. What can we do to make sure these events never happen again? These reports get printed in a flow sheet and are shared daily in our safety huddles. The reports stay opened until closed by the appropriate managers. Each report is followed up by the risk manager and will not be closed until each issue is fixed or corrected. Adverse drug events according to the Center for Disease Control and Prevention cost 3.5 million in extra medical costs each year, and 40% of the costs are estimated to be preventable. (2012). I would begin by collecting information about our medication errors during a span of time, so I can see if...
Words: 1024 - Pages: 5
...Nursing Research Utilization Project Proposal Sally Martin Torres NUR 598 September 11, 2011 Dr. Veta Massey Nursing Research Utilization Project Proposal Section D: Methods of Implementation Health care throughout the history has shown many changes. Every change brings in challenges in a workplace because change is more often met with resistance. It also brings in innovative ideas that steers the organization’s advancement and performance. The major motivation of change in this organization is to sustain a successful future in its continuum. For change to succeed, brilliant strategy, and clever implementation are necessary (Gandossy and Sonnenfield, 2004). Organizing the Plan The problem that was stated in Part A of this proposal was medication error and the organization is aiming at reducing the incidents of administration errors that involve medications. Although there are three proposed solutions, the one that gained the highest priority is the use red disposable apron during the medication rounds. This type of innovation is cost-effective, requiring short staff in-service by the nurse clinical educator, it is maintenance free, and does not require space for storage. This intervention will also allow a less difficult data collection for measuring outcomes. Every institution requires the approval of the Chief Nurse Officer (CNO) to pilot an intervention. The intervention will be introduced in a small 30-bed medical-surgical unit which will last for four months...
Words: 1694 - Pages: 7
...today’s health care system, delivery processes involve numerous interfaces and patient handoffs among multiple health care practitioners with varying levels of educational and occupational training. During the course of a 4-day hospital stay, a patient may interact with 50 different employees, including physicians, nurses, technicians, and others. Effective clinical practice thus involves many instances where critical information must be accurately communicated. Team collaboration is essential. When health care professionals are not communicating effectively, patient safety is at risk for several reasons: lack of critical information, misinterpretation of information, unclear orders over the telephone, and overlooked changes in status.1 Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death. Medical errors, especially those caused by a failure to communicate, are a pervasive problem in today’s health care organizations. According to the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCHAO), if medical errors appeared on the National Center for Health Statistic’s list of the top 10 causes of death in the United States, they would rank number 5—ahead of accidents, diabetes, and Alzheimer’s disease, as well as AIDS, breast cancer, and gunshot wounds.1 The 1999 Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System...
Words: 7203 - Pages: 29
...understand the possible consequences of the act/s, which could include expulsion from Indiana Wesleyan University. Thesis The health care industry each years spends millions in medication errors that could be prevented. By implementing a data entry system that would allow access by medical professionals and pharmacies to collaborate and reduce the chance of medication errors dramatically. The data systems are pricy but when compared to the cost of medication errors and loss of lives it saves most medical establishments money. Annotated Bibliography The need for data entry systems to reduce medical errors Rinda, J. (2012). integration helps clinicians reduce medication errors. Health Management Technology , 33 (10), 12-13. With the risks of medication errors endangering lives, the technology has been gearing towards linking smart infusion pumps with health information platforms. Electronic health records have already been developed and are currently being used in some areas. This can lead to reductions in health care costs and increase in workflow. The medication errors could result in 400,000 preventable injuries each year. 1.5 million errors occur in the U.S. each year, resulting in $77 billion in cost annually. The iv integration system which is a form of the medication entry system, resulted in no iv related medication errors within the first 90 days used at Lancaster General Hospital. With the right implementation any healthcare would be able...
Words: 1839 - Pages: 8
...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
...Negligence Paper Jennifer Zuber HCS/478 April 11, 2016 Susan Lawson Negligence Paper In 1711, Alexander Pope wrote in a poem, "To err is human." Errors happen in every walk of life and every career path, but there are some areas where and error could be the difference between life and death or profound injury. The healthcare field is one of those areas. Over time, health care has evolved. There are now so many practices and protocols in place so that errors may be avoided. It is understood that there are some errors that may occur due to being human, and then there are other mistakes that should never happen, such as surgically amputating the wrong limb. There are so many safeguards in place to prevent such errors from happening. Negligence is a general term that denotes conduct lacking in due care (Guido, 2014). Malpractice sometimes referred to as professional negligence, is a more specific term that addresses a professional standard of care as well as the professional status of the caregiver. To be liable for malpractice, the person committing the civil wrong must be a professional, such as a physician, nurse, accountant, or lawyer (Guido, 2014). Gross negligence is an act or omission “which when viewed objectively from the standpoint of the actor at the time of its occurrence involves an extreme degree of risk, considering the probability and magnitude of the potential harm to others; and of which the actor has actual, subjective awareness of the risk...
Words: 1256 - Pages: 6
...process of development and implementation of a risk management program. The risk management promotes the philosophy of Baptist Hospital of Miami that the risk management and patient safety is responsibility of members of the organization and team cooperation is essential for an effective and efficient functioning. Baptist Hospital of Miami believes that organizational errors should be addressed through the implementation of evidence-based practices, constructive feedback, and learning from error analysis. Clinical errors should be addressed by using the following: • Proper report and analysis of errors related to medical or patient care. • Proactive identification of hazards and unsafe conditions. • Open discussions of mistakes. • Open acceptance of system improvements. The Risk Management Plan at Baptist Hospital of Miami promotes the development, revision, and review of practices and protocols within the organization by taking in consideration risks, loss prevention, and reduction strategies. Disciplinary actions can be taken if evaluated and investigated errors show evidence of willful violations of organizational policies. Specific policies and procedures are...
Words: 2073 - Pages: 9
...Introduction: ABC Hospital is a specialized hospital consists of 600+ beds, which has been designated as a trauma center. It provides evidence based emergency, specialized tertiary patient centered care for Dubai and Northern Emirates. The hospital is committed to its values in terms of services by providing its staff respect, empowerment, accountability, safety and transparency. Its manage-ment team is strongly committed to development of a benchmark hospital with a quality learning environment. It has achieved first Joint commission International (JCI) accreditation in 2007 and has been reaccredited in 2010 and 2013. The basic principles of Quality improvement Plan are those underlying all the quality improve-ment processes: a dedication to continuous improvement in the system and processes as well to identify and satisfy the patient’s needs and recognizing that it can be best attained through team work and employee empowerment (Deming,2000). These principles lead the progress and im-plementation of quality improvement plan. The goal of this plan is to attain organization wide exposure to quality fundamentals and to promote quality structure and processes. Quality Improvement Issues. Patient Satisfaction: As the health care environment is very complex and changes frequently (Gilbert, 1992) due to competition among providers giving more importance to the improvement in efforts and reduc-tion in costs, it makes patient satisfactionverychallenging. There are different kind...
Words: 2813 - Pages: 12
...Study Links Long Hours to Increased Errors | Top Abstract Background Method Results Discussion References | Study Links Long Hours to Increased Errors In 2005, the American Nurses Association House of Delegates resolved to disseminate recent research findings on the relationship between work hours, fatigue and errors. Dr. Ann Rogers presented the results of her study “The Working Hours of Hospital Staff Nurses and Patient Safety” published in Health Affairs, July/August 2004. Her study followed 393 registered nurses working over 5,317 shifts. Each nurse tracked hours worked, time of day worked, overtime, days off, sleep/wake patterns, errors and near misses. According to Dr. Rogers, fatigue results in: * Forgetfulness * Slowed reaction time * Diminished decision making * Reduced vigilance * Apathy, lethargy * Impaired communication. Delivery of health care requires higher cognitive functions – judgment, logic, complex decision-making, memory, vigilance, information management and communication skills. Fatigued workers try ineffective solutions to problems and neglect activities deemed non-essential. Sleep research indicates that most people need at 7.5-8 hour of sleep each night. Nurses in the study averaged 6.8 hours of sleep. Long hours, and the impact of competing priorities in personal lives impact getting adequate rest prior to working. In more than half the shifts, nurses were unable to take breaks due to shift demands...
Words: 2474 - Pages: 10
...Medication errors are “the most common single preventable cause of adverse events in medical practice” [1]. According to the Institute Of Medicine report (IOM, 1999 ), as high as 98,000 patients die in hospitals each year as a result of preventable medical errors [2] which makes medical errors the second leading cause of death in US. . The report further estimates that, medical errors cost the nation approximately $37.6 Billion each year; about $17 billion of those costs are associated with preventable errors. Medication incidents are commonplace in healthcare [1, 2, 3, 4, 5]. In Australian study, out of over 14,000 admission records reviewed, 16.6% of admissions were associated with an "adverse event",[6]. A study by Ahmed E Aboshaiqah...
Words: 937 - Pages: 4
...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...
Words: 11258 - Pages: 46
...system to the hospital will provide ease of information access, protected PHI, and help eliminate errors in our everyday use. IMPORTANCE OF INFORMATION ACCESS Benefits Increase quality of care Bedside charting access Ability to access your patients records at one time All information in one place IMPORTANCE OF INFORMATION ACCESS • The implementation of the EHR will open up the employee to gain access to all the patient records available within one system. This includes x-rays, labs, notes, care plans, etc. • With secured passwords available to each employee, the employ is able to review current and past reports to increase the quality of care for that patient. • Accessing the chart at bedside will help prevent wrong patient errors. PERSONAL HEALTH INFORMATION Vulnerability The wondering eye Hackers Curious employees PERSONAL HEALTH INFORMATION • The patient health information(PHI) will be more vulnerable with the fact that the computer screens either on handhelds or desktops are more easily accessible to everyone's eyes who pass by them. • The risk of hackers getting into the system is also a risk for PHI to be breeched. • Curiosity of employees shows to be a risk involved with EHR. Employees have the risk of entering PHI when they want some information on the patient, even when it is not their patient or relevant to that patients care. PERSONAL HEALTH INFORMATION SECURITY Firewalls Encryption Password protection Limited access Penalties ...
Words: 1060 - Pages: 5
