Premium Essay

Patient Safety Workshop

In: Business and Management

Submitted By iam46709394
Words 9127
Pages 37
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 or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the...

Similar Documents

Premium Essay

Mount Auburn Hospital: Physician Order Entry

...dictionary (2011) a hospital is a health facility where patients receive treatment. Obviously, this definition does not state anything about the kind of treatment, the right or wrong treatment or who does the treatment a doctor, nurse etc. Questions one may not ask oneself till patients receive a wrong treatment. According to a landmark study in 1991 1.3 million injuries occur annually in U.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......

Words: 3064 - Pages: 13

Premium Essay

Emory Healthcare Strategy

...9-311-061 REV: JANUARY 31, 2011 RICHARD G. HAMERMESH F. WARREN MCFARLAN MARK KEIL ANDREW KATZ MICHAEL MORGAN DAVID LABORDE Computer rized P Provide Order Entry at Emory er y ealthcar re He I think the CPOE implementation has gone exceptionally well so far. T These CPOE sy ystems are all pretty immat ture at this po oint in time. I the system we are implem In menting, the m medication reco onciliation mod dule is awful; there are some other things that are awful, but, overall, g ; , given those lim mitations, I thin the CPOE s nk system implem mentation has gone very well g l. — Dr Bill Bornste Chief Qua Officer, E r. ein, ality Emory Health hcare1 La on the drizzly afternoo of June 11, 2009, Dr. Bil Bornstein, Chief Quality Officer of E ate on , ll y Emory 2 in Atl Healthcare lanta, reflecte on the pro ed ogress of the computerize provider o ed order entry sy ystem ntation. (CPOE)3 implemen mory Healthcare’s CPOE p project, a vital cog in a $50 million elect 0 tronic medica record initi al iative, Em began in 2007. Tw years late CPOE we “live” at Emory Univ n wo er, ent versity Orthop paedics and Spine Hospi ital, Emory University Ho U ospital, and W Wesley Woods Hospital i a staged r in rollout.4 Whil Dr. le Borns stein felt good about how t implemen d the ntation had gone thus far, as he looked ahead next m month to July 13, 2009, th fast approa he aching go-live date for Em e mory University Hospital M Midtown (EU UHM) (Exhib 1), Dr. Bornstein thou bit B ught......

Words: 9620 - Pages: 39

Premium Essay

Applying Theory to Practice Problem Part 1

...Applying Theory to a Practice Problem: Part 1: Introduction and Problem of Practice Grand Canyon University Theoretical Foundations for Nursing Roles and Practice NUR-502 Jennifer Wood, BSN, MSN, PhD. January 1, 2015 Applying Theory to a Practice Problem: Part 1: Introduction and Problem of Practice Theory serves as the foundation for understanding the essence of nursing and it gives the nurse the opportunity 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......

Words: 1875 - Pages: 8

Free Essay

Accreditation Audit

...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...

Words: 2353 - Pages: 10

Premium Essay

Medication Safety

...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......

Words: 648 - Pages: 3

Free Essay

Quality Assurance in Hospitals/Health Care Organizations

...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......

Words: 1209 - Pages: 5

Premium Essay

Wrong-Time Medication Administration Errors

...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).......

Words: 1381 - Pages: 6

Premium Essay

Hourly Rounds Reduces Patients

...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......

Words: 2171 - Pages: 9

Premium Essay

Medication Error

...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......

Words: 975 - Pages: 4

Free Essay

Nursing Accountability

...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,...

Words: 420 - Pages: 2

Premium Essay

Case Study

...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):...

Words: 5077 - Pages: 21

Premium Essay

Research

...The primary article for this paper is title Patients Safety Threats and Solution by McCaughan & Kaufman, the article constitutes of nursing standards for safe health care practice. “The article provides great insight of what patient safety is in the health care facility. The article explains that “Many of the harms associated with health care are preventable” (McCaughan & Kaufman 48).The articles provides statistics of accidents that could have been prevented in the healthcare facility. It also explains the importance of using safety methods such as good hygiene, using gloves, washing hands to prevent the spread of disease and contamination. It also emphasizes that “in hospital, medication errors are common” (McCaughan, & Kaufman 50). It refers to medication errors as unacceptable mistakes that can be 100% preventable. Some of the errors are related to malpractice for example, administering wrong dose, administering wrong medication etc. It is inexcusable to see this kind of faults in the health care facility as it can deteriorate one’s health or even end with an individual’s life. The article also emphasizes the importance of communication between individuals in the health care facility. As stated by the article the “Lack of communication can result in family members not receiving necessary information in a timely fashion and a lack of continuity of care from community services, both of which can have serious consequences for patient outcomes”( McCaughan & Kaufman 51). The......

Words: 425 - Pages: 2

Free Essay

Benefits of Teechnology Inmed

...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......

Words: 3378 - Pages: 14

Premium Essay

Evauation of Website for Credibility

...using the Google search engine. The purpose of this website is to enhance and provide guidelines for clinicians, impacts on health care, and knowledge of where products and tools are used. This site also lists tools of improving patient care. A credible website also provides quality of journals, peer-reviewed articles and systematic reviews. I chose this data base for best practice information on current issues. Analysis The ARHQ is a website with a search engine database that is owned and published by the U.S. Department of Health & Human Services. It provides information on evidenced-based practice, provides continuing education opportunities, explores treatment options and gives up to date information on latest news and events. ARHQ is not limited to healthcare providers but is also available to consumers and patients and is labeled for simple navigation. Additionally the website provides a link in Spanish. The website in Spanish is identical for the website in English. The category link for patients and consumers provides information such as “Questions To Ask Your Doctor.” (AHRQ, 2015) The category for professionals provided sources and additional links for furthering education and training, prevention and improving care, and safety. Further evaluation of this website provided a privacy policy notice. It discusses information in regards to what other website collect such as the type of operating systems you are using, the dates, times and amount of......

Words: 1002 - Pages: 5

Premium Essay

Children’s Hospital Case Study and the Relationship with the Readings from Managing Change: Equity & Action

...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......

Words: 1017 - Pages: 5