Introduction
From the perspective of a member of a senior leadership team of an organization, it is important to have an in-depth understanding of medical errors and methods of managing them. A medical error is described as a failure of a deliberate act to be accomplished as anticipated or utilization of an incorrect strategy to achieve a goal (Agency for Healthcare Quality and Research, 2017). These errors include complications with products, procedures, systems, and practice (Agency for Healthcare Quality and Research, 2017). Medical errors can be committed by a physician or ancillary provider or front line clinician, such as a registered nurse, respiratory therapist, physical therapist, certified nursing aid, or medical assistant. With medical
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From the view-point of a senior leadership team member, an error committed by a physician should not change the standard error reporting and investigation procedures that an organization has for medical error. Regardless of who makes the medical error, all medical errors should be taken seriously and actions should be taken. Although physicians eight plus years of schooling and must complete a residency, they are still human and humans make errors. “Causes of Medication Errors in Intensive Care Units from the Perspective of Healthcare Professionals” is a study that describes the cause of medical error from the viewpoint of physicians, nurses, and pharmacists (Farzi, Irajpour, Saghaei, & Ravaghi, 2017). The study was completed using a descriptive qualitative method and the results demonstrated that the medical errors that occurred were related to lack of collaboration between health care teams, lack of pharmaceutical knowledge of the health care group, unsafe drug administration, and incorrect prescribing (Farzi, Irajpour, Saghaei, & Ravaghi, 2017). This study demonstrates that it is possible for all members of a health care team to make a medical error and that rather than changing the way leadership handles the …show more content…
An organization with a culture that values reporting of errors, is objective, flexible, and values learning can help establish a more mindful organization culture and seek out weaknesses within the system and procedures to promote patient safety. To further promote a culture of safety an organization should acknowledge the high-risk aspects of activities conducted in the health care setting and the need to actively attain safe processes, have a blame-free environment, encourage collaboration across the organization, and have institutional commitment to utilize resources to address any and all safety concerns (Agency for Healthcare Quality and Research, 2017). Patient safety culture can be measured through Patient Safety Culture Surveys and Safety Attitude Questionnaires (Agency for Healthcare Quality and Research, 2017). Studies have found that health care organizations that have a weak culture of safety tend to have higher rates of medical error because health care providers do not report medical errors as they occur due to fear of reprimand and this causes the continuation of errors because the organization is not able to learn from these errors and figure out the cause (Singer & Vogus, 2013). As a leader for an organization with a strong culture of safety, the staff would voluntarily and by
The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009).
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
The evidenced based problem that was identified for this research assignment, was that nurses were causing multiple medication errors in a clinical and practice setting. According to the authors Wolf, Hicks, and Serembus (2006), a medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. It is very important for experienced nurses and nursing professors to identify medication errors to prevent them from harming the patient. Some of the errors that were identified were not reported because registered nurses didn’t want their peers to think they were irresponsible (Unver, Tastan, & Akbayrak, 2012). Nurse shaming did not help increase positive outcomes of reporting errors among nursing students and registered nurses (Harding & Petrick, 2008). When medication errors were reported they were not being reported properly, and the consequences for improper reporting were not taken seriously.
The most common kind of medication error is administering the wrong medication or giving wrong doses. A medication error is any error that happens to patients whether they suffer any harmful results or not. Inappropriate nurses-to-patients ratio should be taken into consideration because it can cause medication errors. A new study shows that every year about 210,000-400,000 people who were admitted to the hospital die due to medication error; it also shows that is is “the third leading cause of death behind heart disease and cancer”(MacDonald). For instance, an interview was done with Nurse Carol, a retired nurse; she said that she made a medication error while administering medication to one of her patients. She said that she was rushing and accidentally gave Cozaar to one of her patients instead of Colace. Cozaar is often used for high blood pressure and Colace is for constipation. She said her patient’s pressure dropped very low after taking the medication; she realized then that she gave the patient the wrong medication. Nurse Carol also said that if she did no...
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.
In a culture of safety and quality, all employees are focused on upholding quality in providing safe care. In order to promote patient safety in the hospital setting there should be an exhibition of teamwork irrespective of the different leadership positions. However the leaders show their obligation to quality and safety, and set capacities for their employees to perform a committed and critical role in assuring patient safety.
Institute for Healthcare Improvement. (2011). Introduction to the Culture of Safety (Educational Standards). Retrieved from IHI open school for health professions: http://www.ihi.org
Today, medical error has become a major and important challenge to health care systems across the globe. This is because medical errors often lead to harm that may also be non-repairable (Valiani et al. 540; Denham “Chasing Zero”). In 1999, the Institute of Medicine published a report that indicated that medical error in hospitals accounts for between 48,000 and 98,000 deaths annually (Swift et al. 78; Barger et al. 2441). As such, reducing the occurrence of medical errors has become an international concern. Poorolajal defines a medical error as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.” (Poorolajal, et al. para 5 -10). In this case, it’s very important to acknowledge
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
Many hospitals have systems of checks and balances to avoid errors, but what happens when the systems do not work? Today in the United States, medical errors are the fifth-leading cause of death. In 2000, the Institute of Medicine released a study, “To Err is Human”, revealing an estimated 98,000 deaths annually from medical errors. While this figure is assumed to be lower than the actual, each death comes with an inherent cost to the health care system. In today’s terms this figure is underestimated, however the accompanied cost is estimated to be between $17 billion and $29 billion annually. According to Grober and Bohnen (2005), “Medical error can be defined as, “an act of omission or commission in planning or execution that contributes
For many patients the scariest part of being in the hospital is having to rely on other people to control their life changing decisions. There are multiple causes of patient harm, one of the major contributors are medication errors made by health care professional. Medication errors are inappropriate dispensing and administration of drugs which cause harmful effects such liver damage and excessive bleeding. Most cases of medication errors in hospitals occur as a result of wrong diagnosis by the doctors leading administration of inappropriate drug, poor communication between doctors and nurses and between patients and nurses who issue the drugs. However in an article by the International Journal of Nursing practice, in Australia many occurrences
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
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).
The ‘Role of Short-term Consolidation in Memory Persistence’ by Timothy J Ricker, in the AIMS (American Institute of Mathematical Sciences) Neuroscience journal, is a review article that informs and educates researchers in the neurobiological field, about short-term memory and its centrality to the conveyance of material to the brain. Ricker explains the requirement of short term memory in everyday activities e.g. problem solving and language. Directed towards professional researchers with a profound knowledge on the subject, laboratory research, empahsises the lack of knowledge available in areas of encoding, short term memory and short term consolidation. Thus creating a gap in the neurobiological field and hindering its progression. Moreover, the article goes into great depth on the issues raised in regards to identifying and describing the key differences between consolidating and encoding.
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...