Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
Preventing medication errors institute of medicine 2007
Medication error risks
MEDICATION ERRORS ESSAY
Don’t take our word for it - see why 10 million students trust us with their essay needs.
The “Never Events” is in reference to medical errors that should never occur. Never Events are defined as medical and surgical errors of wrong site surgery, delay in treatment, medication error, wrong procedure performed on patient, suicide, and death by patient using contaminated drugs. The list was altered since then, recently in 2011 and now contains of 29 events gathered in six categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal, stated by, (Patient Safety Network Agency for Health care Research and Quality, 2014). The ramifications of such a policy for pros are the useful awareness being reached out to hospitals, and other health facilities to be mindful of errors. Another
(pro) for this policy is for the government to act on these preventable and devastating errors to fund for more staff, technology, or even more doctors to focus on patients. A policy such as the “Never Events” is not designed to degrade or remind doctors and hospitals how many careless mistakes they do. The purpose is to act on these medical and surgical errors to prevent more from happening. In addition, to all hospitals, doctors, and staff to emphasis to focus more, attention to-detail, and using rational thinking when making decisions for patients is another pro for this policy. The (cons) for this policy is the amount of pressure put on hospitals and doctors and other health care organizations may not pay for medical mistakes. More hospitals and health care organizations might not put out the money to compensate for devastating errors. Not every state may agree to carry out this policy for the fact of medical errors happen and when hospitals can give patients a letter of apology to waive the cost of care.
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.
I chose not to use any of the prompts provided, but instead connect the article to what I learned in my sociology class lass quarter. In class we watched part one of film series of Unnatural causes, titled Unnatural Causes: Is Inequality Making us Sick "In Sickness and in Wealth". While reading the article this reminded me about the cases studied in the film to see whether wealth inequality contributes to making people sick. In the film they focused on the social determinants of health, wealth and education. In both the article and part one of the film Unnatural Causes they focused on three different individuals and how their health are affected by they choices they make and the access they have to care.
“When Doctors Make Mistakes” narrates an event where the author Atul Gawande, a doctor, made a mistake that cost a women her life. He relates that it is hard to talk about the mistakes that occurred with the patient's family lest it be brought up in court. In that instance the family and doctor are either wrong or right, there is no middle ground in a “black-and-white mortality case”(658). Even the most educated doctors make simple mistakes that hold immense consequences but can only speak about them with fellow doctors during a Morbidity and Mortality Conference.
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.
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 following article analysis review by Team B illustrates and identifies several examples of statistics abuse in the practical world as a result of flawed research. The following examples demonstrate how a manger could and in many examples, does make erroneous decisions due to inaccurate statistics. The team has compiled the results by detailing the respective articles.
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
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.
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
Safety is focused on reducing the chance of harm to staff and patients. The 2016 National Patient Safety Goals for Hospitals includes criteria such as using two forms of identification when caring for a patient to ensure the right patient is being treated, proper hand washing techniques to prevent nosocomial infections and reporting critical information promptly (Joint Commission, 2015). It is important that nurses follow standards and protocols intending to patients to decrease adverse
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).
Mistakes often come with discoveries and are key to what you are trying to accomplish. In the passages, there are multiple examples to prove that accidents can lead to creative inventions that can help our society. Many discoveries were originally a simple mistake that lead to something greater. It takes a lot to invent an idea and carry it out, so when you approach it, you should understand what to come. Mistakes are key to discoveries, with examples from the passages, because in “Lost Cities, Lost Treasure: Frank Calvert and Heinrich Schliemann found great things even when they made mistakes, in the second passage “How a Melted Bar of Chocolate Changed Our Kitchens” it states it took Percy Spencer 20 years to perfect the microwave, and in the third passage “In Praise of Careful Science”, it says “without mistakes, no discoveries can be made”.
...g unanticipated events with the patient and families. We have found this gives both the patients and staff comfort knowing the hospital is aware the incident has occurred and we are working as a team on a process to stop it from happening again.
What is one thing in a kitchen that most people use everyday? MIcrowaves. If it weren’t for a mistake then people would not have them. Many discoveries and ideas were made because of mistakes, or accidents. If everything happens the way that someone wants it, then you won't learn something or get something out of it. Also, if something goes wrong, or a mistake happens you will know what not to do next time. But on the other hand, many discoveries are made purely by hard work and research, not just mistakes. Mistakes help people learn, and make new discoveries.