...important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The standards set expectations for organization performance that are reasonable, achievable and rational. Each standard is developed with input from healthcare professionals, providers, employers, consumers, and government agencies like the Centers for Medicare & Medicaid Services. New standards are added only if they are in relation to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured. The National Patient Safety Goals (NPSGs) have become a critical vocal point by which The Joint Commission promotes and enforces major changes in patient safety and quality of care. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness (AHRQ, 2013). Recent changes have focused on preventing hospital-acquired infections and medication errors, in addition to existing goals promoting surgical safety, correct patient identification, communication between staff, and identifying patients at risk for suicide. The most recent update in 2014 added improving the safety of hospital alarm systems as an NPSG. The purpose of the National Hospital Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how...
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...Hourly Rounds Reduces Patients’ Frequent Call Lights and Improves Safety. Christian Oyibe NURS 8103 Evidence Based Practice. Governors State University Professor Somi Nagaraj, MSN, DNP. June 5, 2013. Introduction The nurse call light is an important tool in which patients used to get the attention of nurses during hospitalization. It is one of the many means by which patients can exercise control of their health care. It is done to seek the nurses’ attention for help during inpatient hospitalization. The ideal situation is that when the patient pushes the call light, the nurse or the staff will be there to find out what assistance the patient needs. However, when these calls are made by patients, and there were delays in response time, this will in turn lead to frustration in most cases, and the patient will attempt activities that threatened their safety, thereby leading to falls and other safety issues. In most inpatient hospital or other health care facilities, call lights are made by residents or patients who need bathroom or bedpan assistance. The problem associated...
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...elaborate explanation on managing change. Julie Morath, who was the chief operating officer at the children’s Hospital brought in administration change in the 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...
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...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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...It is zascsanecessary for nurses to stay up to date on clinical practices so that they can provide the best care possible to their patients. “The nurse assumes responsibility and accountability for individual nursing judgments and actions.”(ANA, 2001, p. 1) This paper will discuss evidence-based patient safety practices, focusing on the safety practice of: Prevention of Intravascular Catheter-Associated Infection by use of maximum sterile barrier precautions. There are pros and cons to the short-term use of central venous catheters (CVC) in the hospital. The benefit of having an intravascular catheter is that it allows you to give large volumes and high concentrations of fluids to patients. It also prevents a patient on long-term antibiotics from having multiple IV starts. However, there are also serious complications with the most common being infection.(Shonjania et al., 2001) According to AHRQ, the use of maximum sterile barrier precautions decreases the risk of catheter related infections since many catheter-related infections are caused by contamination during insertion. Maximum sterile barriers consist of sterile gowns, sterile gloves, sterile drapes, non sterile mask, and non sterile cap. Since the nurses are at the bedside to assist with CVC insertions, they are responsible for implementing the guidelines set forth by these safety practices. To do this,...
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...outcomes from medication errors, our company could end up having to pay out large sums of money to deal with repercussions of these errors in legal fees, etc. * Increasing numbers of Adverse Events can lead to a moratorium set on our facility, wherein we would not be allowed to accept any new patients, thereby losing untold amounts of money. A step this drastic can take years to fully recover from. * Having to legally inform the public of each and every adverse event coming from a Medication error could also cost us untold amounts of revenue. The Joint Commission Standard focused on in this summary will be Medication Management. There are three areas covered within the Medication Management Criteria. * Planning Medication Management processes * Labeling of Medications and devices used to administer them * Reducing patient harm in conjunction with Anticoagulant Therapy (Warfarin, Coumadin, Heparin) Standard MM.01.01.01: The hospital plans its medication management processes * We are in compliance with both Elements of Performance (EP’s), which are : 1. The organization has a written policy that describes that the following information about the patient is accessible to licensed independent...
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...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 – Serious Untoward Events Reported from 1 October 2012 to 30 September 2013 21 CHAPTER 5 – Actions Taken and Discussion 26 CHAPTER 6 – Conclusion...
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...Benefits of Technology in Medicine In APA STYLE Abstract Thousands of people die each year as a result of medication errors. Medication errors can be attributed to faults in both humans and medication use systems. Therefore, it is necessary to address resolutions to both of these predicaments. The anticoagulant heparin is amongst the most implicated medications. Thus, it has been documented in the top five high-alert medications. Two notable events that triggered recent interest in this topic are the heparin overdoses that occurred in California, associated with actor Dennis Quaid’s newborn twins, and those affecting neonates in an Indiana hospital. The Failure Mode Effect Analysis (FMEA) is a proactive approach to error prevention. Implementation of an FMEA system would serve as a crucial method that will help to recognize potential failures of a product or process before adverse events occur. FMEA can help identify where the use of technology can be implemented to facilitate the reduction of medication errors, especially pertaining to heparin as in this case. Studies have shown how technology, such as computerized heparin nomagram system (HepCare), smart pump infusion technology, computerized physician order entry (CPOE), and the bar coding system, can reduce medication errors. Expanding nationwide awareness of these methods should result in a significant decline of medication errors...
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...Practice Standard – Safety and Quality Patient safety is a high-priority issue for all professionals including pharmacists. Patient safety is defined as ‘the prevention of harm to patients, including through errors of commission and omission’. The role of pharmacists has been clinically proven to improve many outcomes regarding patient health, including greater patient safety, improved disease and drug therapy management, effective healthcare spending, improved adherence and improved quality of life (Canadian Pharmacists Association, 2008). The focus on patient care stemmed from a 1999 US report by the institute of Medicine titled, ‘To Err is Human: Building a safer Health System’. This report detailed the costs of medical errors to the US economy and how medical errors numbered higher than deaths due to AIDS, motor vehicle accidents, and breast cancer, combined. The report went on to descried how errors can be reduced (Institute of Medicine,1999). For centuries, pharmacists have been the guardians/safeguards against "poisons" those substances which could cause harm to the public. Now more than ever pharmacists are charged with the responsibility to ensure that when a patient receives a medicine, it will not cause harm. As highlighted in a report produced in November 2009 "Pharmacy Intervention in the Medication-use Process - the role of pharmacists in improving patient safety", the involvement of pharmacists in patient safety can be as early at the prescribing phase and...
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...hospital’s labor and delivery unit. It had not been difficult to mount support for the project. POE systems had been demonstrated to reduce error rates, and medical errors were widely recognized as a large and serious problem in health care. A landmark study published in 19911 estimated that 1.3 million injuries occurred annually in U.S. hospitals, 69% of which were at last partially due to errors in patient management. The study found that 13% of injuries resulted in patient death, ‚a rate that if extrapolated to the United States as a whole suggested that approximately 180,000 deaths a year were, at least partly, the result of injuries received during the course of care.‛2 This study also found that adverse drug events (ADEs) accounted for nearly 20% of total injuries (making them the largest injury category) and that 45% of ADEs were the result of errors. A later study at two Boston hospitals found that 6.5% of admitted patients suffered an ADE, and that 28% of these were due to errors.3 1 L.L. Leape, T. A. Brennan, et al., ‚The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II,‛ New England Journal of Medicine 324 (1991):...
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...Medication Safety Medication plays a key role in healthcare but can also be an important key cause of medical error. Patients are entitled to receive safe care including receiving the correct medications. The administration of medication is a daily routine for nurses therefore, it is vital to remember the “Five Rights” of medication safety. The other issue that we are facing on the medical surgical floor is stress. The last issue is that staffs are being interrupted in medication room. Many different things can go wrong when it comes to the administering medication, for example communication between the patient and the nurse could go wrong, or the labeling of the medication, even the dosage can cause improper usage of the drug. The question is what role do nurses play when it comes to medication safety? Nurses play many different roles in the world of medicine; however the most important role is to assure that patients are receiving their medication safely. One of the recommendations to reduce medication errors and harm is to use the “Five rights: the right patient, the right drug, the right dose, the right route, and the right time” (Choo, Hutchinson & Bucknall, 2010). Verifying the patient’s identity ensures that the correct patient is receiving the medication, confirming that the medication written on the order is the same medication being prepared, ensures the right drug, dose and route is given. Some medications must be given at specific time, so it imperative to provide...
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...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 is happening from nursing side. He will assume nurses will give medications appropriately. ISSUE 3 One patient was admitted in Medical ward, was having low sodium level in the blood. And doctor...
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...WALDEN UNIVERSITY NURSING PROGRAM NURSE – 8210- TRANSFORMING NURSING PAPER: MEANINGFUL USE PREPARED BY: ZAIDA RUIZ PROFESSOR: MURIELLE BEENE November 11, 2015 The health care system needed some structure. Needed to speak the same language and have a common goal, “the Patient.” The American Recovery and Reinvestment Act of 2009 (ARRA) invested a large amount of money for promotion and use of the informatics technology. Today Medicare and Medicaid are following the same footsteps. They are awarding incentives for the use of Electronic Health Records. However, what is the urgency? Why are they even willing to penalize the non-participant? Patient safety is the answer. The meaningful use was created seeking the quality of care safety and reduction of disparity. The meaningful use wants patient information to be electronically documented in a database system that interconnects to any other health database regardless geographical location. Meaningful use recognizes that making such a drastic change from paper to electronic documentation is very costly. There are many Issues still present that prevent some institutions from implementing EHR. One of these issues is the financial part that entails. It cost too much to implement EHR’s this is the voice of hundreds of owners of health institutions. Removing the old system from every floor, every station and every office is very costly. On top of that having the employers and employees train on how to use the EHR system...
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...the occurrence of the accident where Matthew was overdosed with morphine. Julie Morath, bringing with her 25 years of experience in patient care administration to the hospital, her main aim was to highlight patient safety and to create a culture where the concept of ‘do no harm’ was explicit rather than implicit. It was very tough to implement as doctors and nurses were not open to discuss any “accidents”. It is an example of classical conditioning as the doctors and nurses used to get defensive when they were broached on the topic of safety. To them, talking about safety implied that that they were doing something wrong. To introduce the idea of enhancing the patient safety, she had to take the doctors and the nurses into confidence. This could only have happened when this plan was implemented slowly. To achieve this she spent time making presentations to hospital staff about national research on medical errors. Then she conducted focus groups to learn more about patient safety issues. Finally she developed a detailed strategic plan for the Patient Safety Initiative. Many problems arised when she tried to present medical accident data to the nurses and the doctors. They were sceptical of the applicability of the national data. To this problem, Morath asked the staff to examine their own experience that week regarding patient safety and was it satisfactory? After discussion they realised that most of their colleagues had experienced similar medical accidental events and...
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...oncology registered nurse. Statistical Information How Statistics are used at my Workplace: There are many memos and emails that are passed around to the nurses that management and administrators hope that we read and absorb. In all honesty, they are glanced at and tossed aside the majority of the time. On rare occasions, we are handed graphs and charts that explain what they expect and shows us specifically what needs to be improved upon. Since our jobs are to care for the sick and hurt, this information is not tossed aside and is typically taken more seriously. One main focus for the nursing staff at my facility is safety scores. We have two medical-surgical floors, one including oncology and the other orthopedics, one intensive care unit, and one step-down intermediate care unit. We all share the same safety goals that are in place to insure our patients not only receive the best possible care but also remain injury free while that care is being provided. Each unit is given a score from 0 to 100 percent based on quarterly fall occurrences and prevention measures. Comparisons are made between each medical floor...
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