PatientSafety1word
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Dec 6, 2023
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Address a Patient Safety Issue
Heather Masserang Date: 4/23/2023
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Address a Patient Safety Issue
Hello, my name is Heather Masserang. I know that this course is geared towards human medicine. But I personally work in an animal emergency hospital as a licensed veterinary technician, and would like to bring some personal experiences into this as-
signment to show that not only do mistakes happen in human medicine, but also veteri-
nary medicine. For this assignment I am portraying the role the patient safety officer for Independence Medical Center. What is a patient safety officer you may ask. A patient safety officer is a healthcare professional responsible for ensuring patients receive safe care. This includes identifying potential hazards and implementing policies and proce-
dures to minimize the risk of errors and accidents (Definitive Healthcare, 2023). It has come to my attention recently that there have been quite a few medication errors given to patients. It is very important to minimize these errors in the future not only for the safety of our patients, but also the reputation of our facility. Health Care Safety Imperative
The United States Food and Drug Administration reports receiving more than 100,000 reports of suspected medication errors each year in the United States. In fact, the leading cause of patient harm in all healthcare facilities is medication errors. According to the National Library of Medicine, 7,000 to 9,000 people die due to a medication error each year in the United States. (Faubion, 2023). Some of the most common medication errors that have occurred in our facility consists of giving the wrong
medication to the wrong patient, not looking at the patients history before giving medication, and verifying with the patient if it is ok to administer the medication. Earlier this week we had two patients that were admitted to our facility that had very similar names and birthdates. We tried to minimize the risk of error by having notes
in their charts that clearly stated that they are to each have their own nurse that way there is one specific person assigned to them. We were hoping that by having a specific
nurse scheduled to each patient each shift hoping that there would be less chance of error, but sadly a mistake was still made. The nurses that we on staff will need to be talked to so that we can understand what happened, and what we need to do to prevent
this mistake from happening in the future.
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Risks If Threats Are Not Addressed
Medication errors can create a great risk to patients. Patients can have a bad reaction to a medication that is given in error which can sometimes become fatal. These
errors can sometimes be fixed by given a reversal agent to bring down any allergic reaction that the patient may be having, as well as extending their care in our facility. The risks that can happen with our employees, is not only their mental health but also their license can be on the line. Our organization will be at risk if we continue making these medication errors our credibility will go down
.
Working in the medical field myself I know when I have made a mistake I personally beat myself up about it, and think about how I can do better in the future. There was one event that I can think of that a patient in our facility was given a blood transfusion the night before but did not use the entire blood unit. In animal medicine you
can use the same unit of blood for 24 hours if the proper care is taken, well I used the same bag because I saw the patients name on it. When I went to to accurately chart the
medical record I noticed that the blood had been expired for 1-2 days before the patient even received it, the first transfusion. I alerted the doctor immediately once I realized the
error of both transfusions. The doctor said it was already done so there isn’t anything that we could do about it now, but we made sure to keep a closer eye on the patient for any type of reaction that didn’t occur the first time. To prevent this in the future I myself have made sure that I check everything twice to make sure everything is going to the right patient, is not expired, and if there is an error that I find from another shift I alert the
doctor immediately so we can continue to give the patients the best care
.
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Another incident that occurred was an overdose of a medication to a patient. A patient was assigned to have a pain injection every 8 hours if needed. The drug that was being given was Methadone with a concentration of 10mg/ml. The orders from the doctor for this specific patient was 4mg, which would have been 0.4ml. The nurse on duty gave 4ml. The doctor was alerted immediately after it was given because the nurse
realized that this was not the correct amount that was to be given. The doctor immediately gave the reversal agent known as Naloxone to negate the effects of the Methadone. This is a great example of an adverse event, it was a medication error that was corrected before it resulted in a patients death
.
The health care safety imperative requires an entire care team to stop before a procedure and verify the correct procedure, for the correct patient, at the correct site. To
achieve this we should use the new technology that we have at our finger tips to our benefit, create a better patient nurse relationship environment, asking others for help if you are unsure, and get more involved by continuing your education. A healthcare safety imperative that can be applied to the case of medication errors, is the Medication Error Prioritization System (MEPS). This was designed with the limited availability of staff and resources in mind and automates part of the medication-error review process. (Polnariev, 2016). A MEPS algorithm uses variables that include error preventability, ability of the organization’s system to detect and/or prevent the error, frequency of the error type, potential for harm of the medication involved with the error, and ability to teach employees how to prevent the error in the future. (Polnariev, 2016). The MEPS also helps to promote enhancement of the culture and safety of an organization. The MEPS has an anonymous reporting system for errors, and report any unsafe practices
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that they witness. The goal of this was to not place the blame on each other or have any
backlash from someone coming forward with concerns. With this method of reporting it could be used more as an opportunities for educational purposes to prevent errors in the future versus punishment. The regulatory agency that has the most oversight with medication error issues is The Joint Commission
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Regulatory Agency Role and Impact
The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm. (The Joint Commission, 2023). The Joint Commission’s National Patient Safety Goals (NPSGs) consist of multiple chapters that focus on ambulatory health care, assisted living community, behavioral health care and human services, critical access hospital, home care, hospital, laboratory, nursing care center, and office-
based surgery. In the chapter that focuses on critical access in the hospital I found the following measures used for medication safety
.
1
.
Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up
.
2
.
Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines
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every time they visit a doctor. (The Joint Commission, 2023
.(
To report an incident to The Joint Commission, the preferred method is to use their online submission form. The Joint Commission advocates the use of patient safety measures, the spread of information, the measurement of performance, and the introduction of public policy recommendations. This organization does not investigate issues that associated with hospital bills or other financial issues, their primary focus is quality of care complaints
.
Potential consequences that can occur for the organization from not reporting errors are legal liabilities which can lead into a lawsuit. A potential consequence for the employees, is punishment whether it be a verbal or written warning, suspension, or if severe enough losing their license. With the patient the consequences can be severe to the point of death. Medication errors need to be prevented to the best of our abilities, that way we don’t face some of these severe consequences
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Role of the Patient Safety Officer
As I have previously stated above the role of the patient safety officer is ensuring patients receive safe care. They also play a role in researching errors that occur as well as analyzing data that can help identify trends of the errors being made. As the patient safety officer I would help to ensure patients get the utmost care by identifying and addressing potential risks. To achieve this I would develop policies and procedures that need to be followed, that would protect patients from harm. I would also be a resource that other staff members could come to when they have concerns, or need a second pair of eyes to reduce the risk of errors. Providing continuing education and new
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medical information would also be beneficial to lessen errors by knowing the newest trends that come out in the medical field. Medicine is changing everyday so to provide the best and safest care to patients, we need to be on top of these changes
.
For the medication errors, the new policy I would try and implement is the buddy system. I know that most of the medical field is severely understaffed at the moment, but taken a few extra seconds can minimize error and further issues in the future. Having a second pair of eyes to make sure it is the right patient, right dosage, or medication can make all the difference. Then in the chart having both sets of initials that
way if there still happens to be any questions we know who to turn to. The nurses will also have to verify with the patient their name and birthdate to make sure that it is correct patient that will be receiving the medication. We will also continue to assign certain nurses to specific patients, and make sure that they are only focusing on the patients that have been assigned to them. By implementing these procedures I think we
will see a decrease in medication errors
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Evidence-Based Best Practice Tools
I think that with the advantage of having technology it can help provide the best practice tools and techniques that can help reduce patient safety threats. With the new advancements of technology we can now facilitate the prevention of adverse events with electronic reference material available at the point of care. Best practice guidelines and drug-reference systems are 2 examples of the available technology we are able to use. Also being able to have the electronic health record systems at our fingertips we can link in current best practice, hospital practice guidelines, and other resources to
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guide care. (Barton, A. J. & Makic, M. F., 2015
.(
Other strategies for lessening medication errors that have been proven to be effective in other organizations are ensuring the five rights of medication administration, following proper medication reconciliation procedures, double or triple check procedures, have the physician or another nurse read it back, consider using a name alert, place a zero in front of the decimal point, document everything, ensure the proper storage of medications for proper efficacy, learning your organization’s medication administration policies, regulations, and guidelines, as well as considering having a drug
guide available at all times. (Vickerie, 2017
.(
Conclusion
So in conclusion the role of the patient safety officer is ensuring patients receive safe care. To prevent further medical errors from occurring I would implement various policies and procedures that would need to be followed, as well as utilizing the technol-
ogy programs we have in our organization. I believe that if we all just took a minute to double or triple check, as well as asking for the help of others we would reduce our pa-
tient risks immensely.
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References
Barton, A. J. & Makic, M. F. (2015). Technology and Patient Safety. Clinical Nurse Specialist, 29 (3), 129-130. doi: 10.1097/NUR.0000000000000128.
Definitive Healthcare. (2023). Patient Safety Officer. Definitive Healthcare https://www.definitivehc.com/resources/glossary/patient-safety-
officer#:~:text=What%20is%20a%20patient%20safety,risk
%20of%20errors%20and%20 accidents.
Faubion, D. (2023). 25 Most Common Medication Errors in Nursing + How to Prevent Them. https://www.nursingprocess.org/medication-errors-in-
nursing.html#:~:text=Medication%20errors%20in%20nursing%20occur,this
%20medication%20error%20may%20occur.
The Joint Commission. (2023). Sentinel Event. https://www.jointcommission.org/standards/national-patient-safety-goals/critical-
access-hospital-national-patient-safety-goals/
Polnariev, A. (2016). Using the Medication Error Prioritization System to Improve Patient
Safety. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699487/
Vickerie, D. (2017). 10 Strategies for Preventing Medication Errors. Minority Nurse.
https://minoritynurse.com/10-strategies-for-preventing-medication-errors/
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