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Samples of medical error
Essay on medical errors
Examples of medical errors
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In the case study identify the incident and explain the problem that might trigger a root cause analysis. In this case study, a patient admitted to the intensive care unit (ICU) with septic shock requiring vasopressors that suffered an MI in the course of his treatment due to vasopressin overdose as the incident. The problem that triggered a root cause analysis was likely related to a log increase in the dose of vasopressin because of a prescribing error, pharmacy issues also figured prominently in this error, the computerized physician order entry (CPOE) system that did not eliminate medication errors and domino effect to the nurse that started the medication that eventually caused the patient to have an MI. The patient in this case was receiving the medication vasopressin, at a dose of 0.4 units/min, a dosage used for gastrointestinal hemorrhage and variceal bleeding rather than the correct dose of 0.04 units/min for treating shock. The vasopressin order was incorrectly written by a resident physician after he received a verbal order from his supervising critical care fellow (Flanders, S. & Saint, S., 2005). The dose that was used for the patient was so high that it acted as a vasoconstrictive agent to reduce the blood flow and facilitate hemostatic plug formation in the bleeding vessel thus causing the MI (complication of high dose vasopresson infusion) (Cagir, B. & Katz, J.). Furthermore, the nurse caring for this patient administered the incorrect dose of vasopressin as a result of the domino effect. In fact, the incorrect dose was given for more than 16 hours, which means that more than one nurse was involved in the error. It was not until a nurse was discussing the medication dosing with nursing students that the incorrect ...
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... Root Cause Analysis in Response to a Sentinel Event. Retrieved on March 2014 from world wide web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdf
Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors. Retrieved on March 2014 from world wide web at http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf
Scott,D.M,A. (2011, May 31). How to Complete an Incident Report. Retrieved on March 2014 from you tube at https://www.youtube.com/watch?v=-MRJUC6HgzQ
WebMD. (2005-2014). Heart Disease Health Center. Retrieved on March 2014 from world wide web at http://www.webmd.com/heart-disease/guide/heart-disease-heart-attacks
Wolf, Zane Robinson & Hughes, Ronda G (n.d.). Error Reporting and Disclosure. Retrieved on March 2014 from world wide web at http://www.ncbi.nlm.nih.gov/books/NBK2652
Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.
Every day there is a constant trust adhered to many different people in the profession of Nursing—the decision of what will help patients in terms of medicine, and the confidence to make these decisions. One false act or one slight misdiagnoses of medication to a patient could be the prime factor in whether the patient lives or dies. Nurses in hospitals across the country are spread thin, and thus makes the probability of mistakes higher. If a medicinal dose is off by even one decimal a patient could die, so the only real answer is for nurses to not be afraid to ask for assistance, always follow procedure and voice opinion is they feel something is wrong.
Christopher death could have been avoided if the Doctor had been able to identify the cause of his desaturation on time. Due to lack of nursing care and many human errors from both the medical team and nurses, it leads to his death as per the inquest. Patient safety was compromised. It was found that Dr. Wooller the anesthetist and Dr. Young the surgeon who operated on Mr. Hammett didn’t investigate on the significant oxygen desaturation event that occurred in PACU while he was transferred from Operation Theater. DR. young assumed it was due to obstructed airway. As Mr. Hammett had Guedels inserted. The inquest stated that the anesthetist was supposed to review the arterial blood gas and transferred Mr. Hammett to High dependency unit due to his desaturation event for more than 20min. The nurses looking after MR. Hammett in PACU was RN Turrell and RN Proud. RN Proud notified Dr. Woller about the desaturation event for which doctor paid the visit but didn’t physically examine Mr. Hammett and left with short conversation. If Dr. Woller had investigated the cause of desaturation event at that time probably they could have prevented the rest desaturation event but unfortunately, none of them were implemented, which lead to additional complication Following the event the deceased was administered bolus morphine for his pain, which was scored 4/10. The nurses working in PACU RN Proud notified the anesthetist about the oxygen stat
Each year this panel of experts put a microscope on patient safety across the board. They decide where upmost attention needs to be paid. Sometimes items leave the list because there are been strides take to improve in that area and sometimes it continues to stay on the list because they believe the relevance and importance is growing. Healthcare is evolving b...
Wu, A. W. (2011). The value of close calls in improving patient safety: Learning how to avoid
When I was working as a bedside nurse in the Emergency Department, in one of my duties I was not satisfied with the treatment plan made by a resident doctor for XYZ patient. He entered intravenous KCL (potassium chloride) for the patient. The purpose of that medication and its dose for that patient was not clear to me. I assessed patient history and came to know that a middle aged patient came with the complaint of loose bowel movements, vomiting, and generalized weakness. His GCS (Glasgow comma scale) was 15/15, looked pale but was vitally stable. I exactly do not remember about his previous disease, social or family history but I do remember that he was there with his son. According to the care plan, I inserted intravenous cannula, took blood
Retrieved from: Ashford University Library Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521.
It’s very difficult to blame someone when mistakes occur in an environment in which we hope learning and improvement will take place. But eventually someone has to take blame for the mistake. Errors can occur anywhere but when it comes to the healthcare field there are more possibilities.It would include acute care, ambulatory care, outpatient clinics, pharmacies, and patient homes. Many people assume that medical errors involve only wrong medications administered or the wrong surgery performed (Dovey, Kuzel, Phillips, and Woolf, 2004). However, there are many other types of errors such as wrong diagnosis, equipment failure; sometimes patients are given the wrong blood (Dovey, Kuzel, Phillips, and Woolf, 2004). As much as the healthcare employees try to prevent medical errors, they still can happen. It is necessary to recognize the medical error in order to provide proper care to the patient, report the error and then take an action to prevent the error from happening again (Dovey, Kuzel, Phillips, and Woolf, 2004).
Kohn, L., Corrigan, J., & Donaldson, M. (1999). To err is human: building a safer health system. Committee on Quality of Health Care in America Institute of Medicine National Academy Press Washington, D.C.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
Three organisations are involved and responsible for the accumulation of road accident information: Transport for NSW, Spinal Cord Injuries Australia (SCI) and the New South Wales Police Force (Transport for NSW, 2012). Centre for Road Safety (CRS) is the primary office responsible for assembling and distribut...
Cleveland Clinic. (2014). How Does Blood Travel Through Your Body? Retrieved on February 18, 2014 from http://my.clevelandclinic.org/heart/heart-blood-vessels/how-does-blood-travel-through-body.aspx
According to the Institute of Medicine (IOM), patient safety is defined as the prevention of harm to patient. Within the system of care, they put an emphasis on error prevention, learn from errors that occur, and is built on a culture of safety among health care professionals, organizations, and patients (Mitchell, 2008). It is important for patient safety to be a priority in health care because they are already in the hospital for an illness we do not need to add to the problems they already have. It is imperative to look at patient safety from an individual, health system, and community level.
The theme of the reading this week was centered around QSEN competency of patient safety. I was disappointed to read in “To Err Is Human: Building a Safer Health System” by the Institute of Medicine that, in the United States alone, between forty-four thousand and ninety-eight thousand people die annually hospitals due to preventable errors and that these errors cost hospitals between seventeen and twenty-nine billion dollars. I was surprised to learn that there are more accidental hospital deaths than deaths from motor vehicle accidents. Healthcare is ideally is supposed to do no harm. The approach to improve patient safety, according to “A New Mindset for Quality and Safety…”, must make changes to the system. Past protocol was to reprimand
Medical error has been identified as a major threat to patient safety. It is responsible for 44,000-98,000 deaths per year and the leading cause of this error related to inpatient deaths is adverse drug events with estimated 7,000 death annually.