...Topic: Medication Errors Don’t Let Them Happen to You I have learned from the article that the consequences of medication error are severe, I believed it the responsibility of myself a student nurse and every nurse to ensure that accurate measure are followed as they greatly influence medication used. Accurate measures will include; Patient information this is very important to meds administration because it helps the nurse identify who exactly their patients are. Another important fact I took into consideration when I read the article was the “five rights”. I believe accurate patient demographic such as name, age, date of birth, allergies and history of infection gives the nurse, the rightful information that identifies the patient every time they access the patients’ medical information. Such information will correctly help nurses in choosing the appropriate drugs, dosage administrator, and the frequency of the route. The patients age is another important aspect in providing the right dose since certain drugs are only given to specific ages of people while allergy history of a patient helps the nurse accept or decline to issue medication that they believe would result in serious allergic reactions with the patient. Another aspect nurses need to take into consideration when preparing medications is the environment. It’s very important that nurses dispense medication in a quite environment to avoid distraction and med error. It is important for nurses to be free from stress...
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...Unfortunately this story does not resonate with some Americans 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...
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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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...problems. Along with growth there are more opportunities for mistakes; and all staff members must view these errors as areas for development. The purpose of the Quality Improvement Department is to direct and guide output of employees within the organization toward providing safe and efficient health care services. If our hospital is expanding rapidly it’s crucial that the organization has the necessary capacity and resources for operating under these conditions. Anticipating patient volumes and determining the scope of health care services to be provided are important considerations that should be taken into account. The problems this health care organization is experiencing are closely associated with the growth of the hospital and appropriate action must be taken. Creating a Quality Improvement Department is a strategic investment which will substantially increase our ability to provide safe, high quality and efficient care. This unit is specifically designed to assist in maintaining compliance with state and federal regulations, guiding employee actions towards completing organizational objectives, and establishing standards of quality, safety and efficiency. Our hospital can utilize the QI department to organize the efforts of our entire staff and drastically improve patient safety issues. In order to properly address problems with patient falls, medication errors and hospital acquired infections the organization requires a unit dedicated to quality improvement. ...
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...happened on the previous shift, this would take away valuable time from the patient and could lead to negative patient care. By using documentation this type of communication provides a legal record of care for each patient. The LTC facility uses several documents to monitor each resident’s care and the outcomes from the care. Each resident also has a personal medical record (PMR) these record contain the resident’s medical, family, social history, assessments, dietary needs, treatment plans, orders, prescriptions, progress notes, and lab results. With this chart the LTC has a complete and accurate look into each individual resident and their medical history and progression of care. Included in their record the, Medication Administration Record (MAR) this is used to document the time, dose, how and when it was administered by the nurse. This record also provides communication in regards to new physician orders, which would include changes for a new medication or discontinuation of a medication. The nurse that distributes the medications must chart immediately when the...
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...Thesis Statement A patient prescribed a Dysphagia Mechanically Advanced Diet can have certain oral medications crushed and mixed with food at a consistency appropriate for the patient. Pathophysiology On October 6, 2015, in clinical, I cared for an 82 year-old female named Ms. M. She had presented to the hospital Emergency Room with altered mental status and shortness of breath. Ms. M had a past medical history including Parkinsonism resulting in dysphagia. The abnormal lab results that supported the eventual primary diagnosis of a urinary tract infection and possible sepsis include an elevated Absolute Neutrophils Count (ANC) 72%-normal ANC 55%-70% and decreased Absolute Lymphocyte Count (ALC) 16%-normal ALC 22%-44%. (Pagana & Pagana, 2013)...
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...Medication errors that result in death, physical and/or mental challenges are inexcusable to the patients and their loved ones. There are several types of medication errors and prevention begins with recognizing the causes and developing possible solutions in order to limit the occurrences. Prevention of these errors is an immediate need considering the analysis that they are one of the leading causes of medical grievances in the United States. Infant Death In the case study, “Understanding the Causes and Costs of Medication Errors”, a medication error lead to the death of an infant who was one day old. There were more than fifty latent and active failures that occurred throughout the series of events that lead to the infant’s death that began with the pharmacists and ended with the nursing staff. The laws that were broken in this case weren’t in the hands of a single individual or component however; there were liable parties: nursing staff, pharmacist, manufacturer, physician, health department, and hospital administration. Laws Broken The administration of a medication act is when a single dose of a prescribed drug is given to a patient by an authorized person in accordance with the federal and state laws and regulations, (Pozgar, 2009). This law wasn’t adhered to by the nursing staff involved in this case. The unauthorized nurse practitioner altered the way the medication was prescribed to the patient by administering the medication through an IV instead of an...
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...MedDRA® TERM SELECTION: POINTS TO CONSIDER Release 3.13 Based on MedDRA Version 12.1 ICH-Endorsed Guide for MedDRA Users Application to Adverse Drug Reactions /Adverse Events & Medical and Social History & Indications 1 October 2009 © Copyright ICH Secretariat (c/o IFPMA) Copying is permitted, with reference to source, but material in this publication may not be used in any documentation or electronic media which is offered for sale, without the prior permission of the copyright owner. IFPMA Chemin Louis-Dunant, 15 P.O. Box 195 1211 Geneva 20 Switzerland Tel: +41 (22) 338 32 00 Fax: +41 (22) 338 32 99 2 Table of Contents 1.0 1.1 1.2 1.3 1.4 2.0 2.1 2.2 2.3 2.4 2.5 2.6 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 3.23 3.24 3.25 3.26 4.0 4.1 4.2 INTRODUCTION ...................................................................................................................... 4 OBJECTIVE OF THIS DOCUMENT ................................................................................................. 4 PURPOSES OF USING MEDDRA ................................................................................................. 5 BACKGROUND ........................................................................................................................... 5 SCOPE OF THE POINTS TO CONSIDER ......................................................................................... 6 GENERAL PRINCIPLES...
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...generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter as well as supporting other care-related activities directly or indirectly including evidence-based decision support, quality management, and outcomes reporting. A government-sponsored survey of the use of computerized patient records by doctors points to two seemingly contradictory conclusions, and a health care system at odds with itself. Skip to next paragraph A government-sponsored survey of the use of computerized patient records by doctors points to two seemingly contradictory conclusions, and a health care system at odds with itself. The report, published online on Wednesday in The New England Journal of Medicine, found that doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care. Yet fewer than one in five of the nation’s doctors has started using such records. Bringing patient records into the computer age, experts say, is crucial to improving care, reducing errors and containing costs in the American health care system. The slow adoption of the technology is mainly economic. Most doctors in private practice...
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...including physicians, pharmacy staff, nurses, administrators, and IS operations staff. The POE system was scheduled to ‚go live‛ on a pilot basis in the middle of October in the 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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...S. hospitals of which 69% are partially due to errors in patient management and 13% of these resulted in a patient’s death (Mcafee, Macgregor, Benari, 2003.) Also the Mount Auburn Hospital in Cambridge, Massachusetts became aware of the landmark study (1991) and is therefore preparing to set up a physician order entry (POE) system throughout their hospital. The labor and delivery ward will first use the POE system. The new POE system will be able to replace paper-based and verbal medication ordering processes with an information system. A doctor will enter the patient’s medication order via the new system, which will next transfer that order to the internal pharmacy. Mount Auburn faces the challenge of how to introduce the new system successfully to its new users. In addition, medical error rates at the Mount Auburn Hospital can be decreased through the implementation of a POE system, because it will improve the communication of the drug order between the physicians, nurses and pharmacist and it can guarantee available drug and patient information. This paper starts by explaining the reasons for errors occurring in hospitals. The second sections deals with the implementation of a POE system at Mount Auburn hospital. Next the paper focuses on the positive impacts of the POE system. The last section describes the limitations of a possible implementation. 2. Reasons of Errors The National Coordinating Council for Medication Error Reporting...
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...Safety Among the key challenges of patient care, quality, and safety is to ensure that there are no injuries to patients from the care intended to help them. Another challenge is to provide care that is respectful of and responsive to patient preferences, needs, and values. Since the nation's health care system is prone to errors which can be detrimental to quality and safety. In fact, a variety of stakeholders are responsible of ensuring that patient care is delivered with the highest quality standards and that no harm occurs to patients. However, the possibility of errors is...
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...be selected and the most practical for Western Governors University Hospital to adopt. The current hospital record management system is paper based requiring several paper forms containing various information from different interdisciplinary teams incorporated from a patients history of hospital stays. Often, forms are not updated to reflect current patient information, lost between departments or vital information is not correctly incorporated. It is also common practice that multiple copies of the same information exist within the hospital setting posing a risk for inconsistencies of data sources. Within a hospital setting it is imperative that procurement, management and recovery of large volumes of information be easily accessible to anyone with direct medical contact with a patient. Such information would include; patient medical and personal information, health history, staff information, medications, allergies, labs and testing results as well as physician consultations. This system will also track staff that have input, reviewed and collected information on a patient. An electronic medical record system will help the hospital run more efficiently and reduce the number of possible errors by consolidating data, standardizing data...
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...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...
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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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