...To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking...
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...Implementations 12 Justification 13 References 14 Introduction Attention to medical errors escalated over five years ago with the release of a study from the Institute of Medicine (IOM), To Err is Human, which found that between 44,000 and 98,000 Americans die each year in U.S. hospitals due to preventable medical errors. Hospital errors rank between the fifth and eighth leading cause of death, killing more Americans than breast cancer, traffic accidents or AIDS. Serious medication errors occur in the cases of five to 10 percent of patients admitted to hospitals. These numbers may understate the problem because they do not include preventable deaths due to medical treatments outside of hospitals (Vantage Professional Education, 2009). Background Medical malpractice is professional negligence that can cause injury which may result in death, substantial economic damages to the patient. Most cases of medical malpractice involve inaccurate diagnosis or misdiagnosis. There has been various and unfolding problems occurring in the United States domestic healthcare for many years. The most grave problem experienced in the healthcare industry is the suborn increase of medical errors in the healthcare industry. Some of the most serious incidents observed in medical errors include: misread handwritten prescriptions. Wrongly prescribed medication and improper dosages administered to patients during hospitalization...
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...Introduction This aim of this research review paper is to discuss the various types, causes and cost for medical errors. After reading this paper, the reader should be able to realize the importance of understanding the know how of medical errors and also understand how various interventions can be used effectively to prevent such errors. The paper also aims to stimulate critical thinking in terms of awareness about medical errors. I have worked in the critical care field for eight years in the past and have been a part of policy implementation with regards to medical errors. Most of the thoughts discussed in this paper are research-based, however, a few are from my personal and professional experiences working in the intensive care field. Causes of Medical Errors A. Diagnostic 1. Error or delay in diagnosis Failure to diagnose an ectopic pregnancy causing rupture and possible acute abdomen. The reason could be either because the obstetrician did not feel the need to order an ultrasound thinking the mild complain of pain to be insignificant to warrant an ultrasound or on the other hand, the radiologist fails to identify an ectopic pregnancy while performing an ultrasound, either due to incompetency or due to negligence. 2. Failure to employ indicated tests Failure to check blood glucose levels for a known hypertensive patient who presented with altered or loss of consciousness. Delayed checking of blood sugar was found to be 20mg/dl] 3. Use of outmoded tests...
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...MEDICAL ERRORS 2 Abstract Patients rely on health care professionals and institutions for their safety and well-being (“Quality and patient,” 2009). According to Agency for Healthcare Research and Quality (2000), “medical errors are responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year. Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital, and preventable health care-related errors cost the economy from $17 to $29 billion each year”. In addition to the monetary cost of errors, the physical and psychological costs such as pain, loss of loved ones, human suffering, disability or death are the greatest indelible mistakes. Medical errors lead to distrust of the health care system and drive patients away from visiting doctors leading to poor utilization of the health care system and consequently worse health care. Researchers estimate that about half of all medication errors are preventable. They suggest that when a medication error occurs, it is not the result of a single mistake, but rather a series of breakdowns in the health care delivery system therefore, this suggests that more checks and balances in patient care could prevent or remediate medication...
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...for pain instead of Joshua Jenquin. Patients worry about the bad outcome of the medical error caused by getting treatment in a healthcare facility (Robbenolt, 2009). Besides, patients care about what happened to them. Patients should, therefore, receive an apology to ensure similar error do not occur in the future. About 18% of patients indicate that the physicians have knowledge about the medical error. According to Robbenolt, 2009, "this range from a simple acknowledgement of the error to various forms of apology (p. 2)." About 98% of patients would want the doctor to tell them that they are severely sorry (Robbenolt, 2009). Patients expect to be informed promptly about a medical error (Robbenolt, 2009). The patient also need to know how the error occurred, what steps would be taken to prevent future harm and receive an apology (Robbenolt, 2009). Some patients even file a lawsuit (Robbenolt, 2009). Because of this, the litigation attorney are motivated to find out what happened so that they can prevent future occurrence (Robbenolt, 2009). The reason 90% of patient file a lawsuit is to prevent the same thing from happening to someone else (Robbenolt, 2009). About 40% said they would not file a lawsuit if they received an explanation of how it happened (Robbenolt, 2009). Apologies may also facilitate settlement claims (Robbenolt, 2009). When the physician assumed the responsibility of the medical error, patients are less likely to seek legal advice (Robbenolt, 2009). Patients were...
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...What is the Meaningful Use of an EHR? Preventing Medical Errors and Early Cancer Diagnosis HCIS/275 Ms. Smith November 6th, 2015 Amy Filler What is the Meaningful Use of an EHR? Preventing Medical Errors and Early Cancer Diagnosis In the case study that I read the people talk with a Dr. Frank Maselli. Dr. Meselli is a family physician at a family practice in the Bronx. They ask him about his experience with using the electronic health records. They question him if he thought it helps not make errors in his office and if he thought it help him diagnosis patients quicker. Dr. Meselli informed them that using electronic health records did in fact allow his office to be able to store and use medical records a lot easier than before. It is also having a great impact in his ability to care for his patients better. He was impressed of how well the e-prescribing worked as well. He liked how there was very little error when you sent it electronically unlike before when the pharmacies would have to call all the time because something was wrong. They have a color system and his employees know if it is green they are good to go, yellow then there is only partial coverage and red means no coverage. He notices how this system diagnoses his cancer patients. The system helped him identify 3 cases of breast cancer and a case of colon cancer. With Dr. Maselli using electronic health records it help him make 4 people healthy because he was able to diagnose and treat each patient earlier...
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...Running head: Medical Error Disclosure of Medical Errors Patrick Jean Lemur HSC 545 November 19, 2012 Professor Maureen Lancellot Those in the health care industry in one capacity or another are aware that medical errors are very common in the industry from the clinician doing bedside care to the chief operating officer responsible for the management of large corporations. It is an issue that has been debated for a while and is still a hot topic to this day. Several manuals have been written from ways to prevent occurrence to reasons errors should be disclosed, and the list goes on and on. Medical errors are common occurrence in every day clinical practice, and even with all the preventive measures set in place, errors continue on taking place and some more serious than others. Should all medical errors be reported? This is an important issue for the leadership of a healthcare providing institution in terms of ethics. In view of the magnitude of this issue, medical errors, disclosure, ethical responsibility of healthcare institutions would always be common in all discussions. There is different type of medical errors; mostly it is understood to be an event that occurs where care was inappropriately delivered and the outcome results in physical or emotional disturbance to a patient. It can be classified as human error, sometime mechanical however there is always human involvement in some degree. The concept of beneficence professes that care should be given and no...
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...Medical errors are a major challenge in most hospitals. The major factors that lead to such errors are intimidation of nurses and condescension from physicians and other medication prescribers. I agree with the findings since they are reliable in making the necessary changes geared towards minimizing the medical errors. Intimidation and arrogance cause nurses to make most of the medication errors. Some healthcare providers fail to consult the right people for the fear of sanctions (Kalra, 2011). However, hospitals are trying to change their cultures to enhance communication between the various departments in the hospital to prevent a recurrence of such mistakes. The nurses and pharmacists face the challenge of determining the right prescription to give patients, and they end up carrying out research on the possible usage of a particular medicine due to fear of sanctions....
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...three was to take the information that I learned in my research paper and transform is into three different genres that would target three different audiences. My research paper focused on medical writing and some topics that lay within it. In my paper I gave a background in medical writing history and then talk about it in the present day. I cover prescription writing errors, becoming published and writing in medical school. I chose to take my information on the history of medical writing, prescription errors, and becoming published and transform it into different genres other than a research paper. Along with changing the genre that the information is presented in I must also repurpose it with the intention of targeting...
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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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...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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...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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...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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...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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...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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