Error Prevention and Patient Safety

Chasing Zero is documentary named “Winning the War on Healthcare Harm” directed by Dennis Quaid which highlights the stories of preventable medical errors. I choose the story of twins of Dennis Quaid. They are the victims of preventable medical error which encouraged Dennis to brought stories of preventable errors in attention to healthcare personnel’s. Twins received overdose of Heparin in Cedars- Sinai’s hospital and they were very close to dying as per their dad. During the time of 8 hrs they received 2 times overdose of this medicine.This error happened due to negligence in recognition of the Heparin vial. 10 units Heparin vial is very similar to 10,000 units vial. The only difference between these two vials was the color of lid. After this incidence Baxter, medication manufacturer made changes in labels of both vials. These type of errors are preventable with bar code scanning. We can realized the importance of bar-code scanning by learning about these type of errors. In 1997, the National Patient Safety Foundation was created with a singular mission of ensuring safe care of patients.Several other organizations working on there mission to improve quality and patient safety( Denisco & Barker, 2016).

What strategies can APN’s employ to prevent errors and contribute to a culture of patient safety?

Advanced Practice nurses role is very wide in healthcare field. APN’s have to make sure that they enter orders for medications in eMAR by themselves to avoid errors. Clear loop communication with Physicians, nurses and other members of health care team. Performing medication reconciliation at every transition point is critical to ensuring patient safety, preventing unnecessary re-hospitalizations, and reducing the risk for medication misadventures.

How can accrediting and regulatory bodies influence quality measurements to improve patient safety?

The Joint Commission and Centers for Medicare and Medicaid Services encouraged to focus on Evidence – based practice which is most imperative in improving patient safety and quality of care.

Proper training of staff regarding preparing, dispensing, handling and administering high alert medications.

Continue education can be great source to prevent these errors.

Quality improvement committee plays important role in regularly auditing the errors happened.

Peer-reviewed journal references:

Fitzgibbon, Marie, DNP,R.N., C.R.N.P., Lorenz, Rebecca,PhD., R.N., & Lach, Helen, PhD,R.N., G.C.N.S.-B.C. (2013). Medication reconciliation: Reducing risk for medication misadventure during transition from hospital to assisted living. Journal of Gerontological Nursing, 39(12), 22-9; quiz 30-1. doi:http://dx.doi.org/10.3928/00989134-20130930-02

Beyea, S. C. (2009). Anticoagulants: Be alert for errors. Association of Operating Room Nurses.AORN Journal, 89(1), 203-5. doi:http://dx.doi.org/10.1016/j.aorn.2008.12.018

References:

Denisco, S. M., & Barker, A. M. (2015). Advanced practice nursing. Burlington, MA: Jones & Bartlett Learning.

“Chasing Zero: Winning the War on Healthcare Harm” video (53:00) from the QSEN Institute: http://qsen.org/videos/chasing-zero-winning-the-war-on-healthcare-harm