I started off by watching a few minutes of each video that was provided as our options. All of the videos looked interesting, but the one that intrigued me most was Chasing Zero: Winning the War on Healthcare Harm. Chasing Zero: Winning the War on Healthcare Harm is a documentary that discusses about the immense problem of medical errors and includes different ways and ideas on how to reduce the risk of these errors. This documentary also shows the impact medical errors have on a family’s life by showing us directly how some of the families that have been affected. Dennis and Kimberly Quaid were of the the families that went through this nightmare when their twins were accidently given Heparin (1,000 times stronger) instead of Hep-lock. Fortunately for the The Quaid’s family this avoidable medical mistake didn’t cost the twins lives. From watching this video, I learn how most medical errors aren’t always simply due to the caregiver’s performance or practice, but instead can be accompanied by the flawed systems. In the twins’ case the error was made due to human error, but the fact Hep-lock and Heparin were in a similar colored bottle and labeled similarly made it more difficult to distinguish between the two. I also learned about different techniques and technologies health care workers are trying to use to prevent medical error by improving old processes and systems or creating new ones. Check a box, save a life is one of the newer interventions, it is essentially a check list for resident surgeons (if used each resident is estimated to save a life). The barcode technology is also something newer that can help save lives by doing a safety check of the five rights for medication. In the video it is stated that leadership, safe p... ... middle of paper ... ...estions if not 100% sure of something or use a double checking system. When a nurse is administrating medication, they should use the ten rights of medication administration (right patient, right drug, right route, right time, right dose, right documentation, right action, right form, right response, and right to refuse). Nurses should always keep good hand hygiene and always wear appropriate clothing to prevent from the spread of disease. Good communication with patients and healthcare team members is also key to success. Keeping on the eye on the patient within an appropriate time is important. If the patient ever seems to be looking different than their usual self vitals should be taken immediately. Encouraging patients to ask questions if they are unaware of something can prevent errors as well. Nurses should make sure the patient is on the same page as they are.
Chasing Zero is a documentary which was meant to both educate the viewer on the prevalence of medical harm as well as to enlighten both the public and health care providers on the preventability of these events (Discovery, 2010). The documentary expounded on the fact each year more people die each year from a preventable medical error than die due to breast cancer, motor vehicle accidents or AIDS (Institute of Medicine, 1999). Medical harm can result from adverse drug events, surgical injuries, wrong-site surgery, suicides, restraint-related injuries, falls, burns, pressure ulcers and mistaken patient identities (Institute of Medicine, 1999). Incidences of medical error have been reported in the media for many years. The most startling revelation in the documentary is how common medical errors are and how preventable they are.
Kohn, L. et al. 2000. To err is human: building a safer health system. Washington D.C. National Academies Press.
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
4). Examples of how nurses can integrate this competency include; using current practice guidelines and researching into hospital’s policies (Jurado, 2015). According to Sherwood & Zomorodi (2014) nurses should use current evidence based standards when providing care to patients. Nurse B violated one of the rights of medication administration. South Florida State Hospital does not use ID wristbands; instead they use a picture of the patient in the medication cup. Nurse B did not ask the patient to confirm his name in order to verify this information with the picture in the computer. By omitting this step in the process of medication administration, nurse B put the patient at risk of a medication error, which could have caused a negative patient
Sicko, a film by Michael Moore was released in 2007. The film investigates health care system in the United States. One would definitely get amazed by the facts and figures explained in this documentary. The movie explains failing health care system in the United States. America has advance medical technology, big hospitals, and educated health care professionals, but these facilities are not universal. The film starts by talking about true American stories; what some people have experienced from current health care system, those who had and did not had health insurances. The story starts by Adam, one of 50 million people in America who does not have health insurance. Due to an accident Adam required a medical treatment, but for the reason of not having any insurance he puts stitches on his leg by himself. The second story was about Rick, who accidentally cut the top of his two fingers, middle and the ring while working on the table saw. As a result of not having health insurance, Rick could not put the top of his middle finger back because it was costing 60,000 dollars and he did not had the money. So, he decided to put his ring finger back because it cost 12,000 dollars which he could afford. The movie does not go into the detail of 50 million people who do not have health insurance, but it’s about 250 million Americans who do have health insurance.
In “Sicko,” Michael Moore presents the flaws of America’s health care system that has been in continuous debate for many years. Despite the government’s obligation to help people, there are nearly 46 million Americans without any health care coverage, because they either are not able to support such costs or have been rejected by the health insurance companies. Thus, Moore claims that because America’s current health care system is incompetent and morally corrupt, the federal government should provide universal health care for all citizens, since America’s health care companies do not consider the rights of American citizens and make fraudulent decisions to make profit. Throughout his film, he also uses ethos, logos, and pathos to highlight the necessity of America’s private health care system to be replaced with universal health care.
Woo, A., Ranji, U., & Salganicoff, A. (2008). Reducing medical errors with technology. Retrieved March, 2012, from http://kaiseredu.org
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.
The medical secretary, registered nurses, licensed practical nurses, and physicians communicated consistently and appropriately so that all staff could effectively complete the actions required of their respective roles. I noted the strong relationship between the nurses and the physicians. The nurses held a heavy influence on the physician’s decisions regarding a situation, because the nurses were the ones conveying pertinent information related to the patient’s status. Based on the information provided, the physician would make recommendations and provide guidance to the nurses. The physician’s directions were then carried out by the nurse, influencing the nurse’s plan of care for his/her
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.
It is not unheard of for a nurse to accidentally make a medication error by not following the five rights of medication administration; this could potentially harm a patient. If the nurse reports the mistake right away to their supervisor, regardless of the consequences and makes sure the patient is safe they are being honest and acting in the best interest of their pat...
In saying 1.5 million Americans have witnessed hospital errors in the care of the medical center or even 40,000-100,000 deaths is a ridiculous amount of faults. Errors should be minimized, especially when dealing with people’s lives. The number of deaths is so high hospitals should take notice and really pinpoint where their facility is miscalculating and create in-service training to all employees and not just the ones that are making the errors but all employees. This will decrease the chances of errors made in the hospital. With continuous training every month there can be a huge change in the number of mistakes. The fact that these inaccuracies are even causing deaths really highlight the importance of the need for a change. Families
All in all, administering medications takes a great deal of responsibility and care to prevent errors from occurring. It is also important to know that administering medications to the elderly can be significantly different because of their physiological changes. Finally, it is important to have a system like the six rights and three checks to consonantly screen against medication errors.
Drug administration forms a major part of the clinical nurse’s role. Medicines are prescribed by the doctor and dispensed by the pharmacist but responsibility for correct administration rests with the registered nurse (O'Shea 1999). So as a student nurse this has become my duty and something that I need to practice and become competent in carrying it out. Each registered nurse is accountable for his/her practice. This practice includes preparing, checking and administering medications, updating knowledge of medications, monitoring the effectiveness of treatment, reporting adverse drug reactions and teaching patients about the drugs that they receive (NMC 2008). Accountability also goes for students, if at any point I felt I was not competent enough to dispensing a certain drug it would be my responsibility in speaking up and let the registered nurses know, so that I could shadow them and have the opportunity to learn help me in future practice and administration.
Baccalaureate nurses are responsible for providing and ensure our patients safety. The knowledge from others mistakes can help informs nurses of extra precautions that we can take to ensure our patient’s safety. Risk Analysis and Implication for practice course helped me understand the steps I as a nurse can take as well as the facilities I work for to help reduce the number of medication errors that occur. Interviewing the pharmacist help me get a better insight to what facilities already have in place to help prevent medication errors. However like most things you have to have educated and compassionate caring staff to enforce and follow the guidelines set in place.