7 PDSA
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School
University of Illinois, Springfield *
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Course
MISC
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by ChiefDragonfly3093
Patient safety Assignment
1.
Scenario
A patient admitted in the ICU was on heparin infusion. The attending physician ordered to
discontinue the infusion and start oral Eliquis 10 mg . The RN was in hurry as shift was
changing so did not update charts about discontinuation. The RN on next shift did not see
any discontinuation instructions. Thus, patient was now getting heparin infusion as well as
PO Eliquis. (Both are anticoagulants.) Patient presented multiple bruises over abdomen and
nosebleed in few hours. He was given protamine sulfate to counteract heparin and
monitored strictly. Luckily patient survived without further harm.
2.
Patient Safety Issue
Heparin is a high alert medication. Patient could have serious life-threatening condition if not
given reversal agent quickly, including cerebral hemorrhage and death. Duplicate medication
error in such cases are highly fatal.
3.
PDSA ‘resolution’
Plan
Study and analyze scenarios with duplicate medicine orders reported in patient safety
reporting systems.
define a safety report as a duplicate medication order error if the report
described a duplicate medication or medication within the same therapeutic class that was
ordered unintentionally.
Define the types of duplicate medication order errors and the context under which these
errors are occurring. Examine the potential factors contributing to these errors.
Do
A clinical team could evaluate instances, such as heparin and eliquis being ordered together
and decide if there should be a hard stop or other system design to prevent them from both
being ordered as active medications.
Make Electronic Health Record (EHR) alerts more comprehensive.
Facilities should collect
more detailed information on the health IT systems involved in duplicate medication
order errors.
Study
Observe the changes made in the system and if they are reducing the duplication errors.
Review the frequency of duplicate medication error alerts and examine adherence to these
alerts. When alerts are bypassed, facilities should analyse the context surrounding the alert
to understand why it may have been bypassed and adjust the conditions triggering the alert
accordingly.
Act
Defining roles and improving communication among team members to prevent duplicate
medication order errors.
Customizing and using context-specific alerts, manufacturing databases, and EHR algorithms
to identify and check for duplicate or additive medication order errors and maintaining a
pharmacist role for error recovery.
Gaps in care coordination and communication issues that may be contributing to duplicate
medication orders could be identified by conducting a Failure Modes and Effects Analysis
(FMEA) to evaluate information flow during transitions in care. Using an FMEA may allow
facilities to pinpoint specific weaknesses and develop processes to address these
weaknesses.
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