Care After Medication Error
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| September 21, 2013 Ms. A was a sweet older lady with a bad heart who was transferred all the way from Montana in order to medication error in care homes get expedited workup for cardiac (heart-related) surgery. Her story of her symptoms
Medication Error In Nursing
and disease course was the story told by hundreds of patients seen at any given hospital every year. It medication error articles started with a few weeks of chest discomfort while walking, followed by a day of chest pain, nausea, vomiting and dizziness prompting an urgent 911 call. Where she thought her
Medication Error Stories
symptoms were attributable to bad heartburn, the studies at her local hospital demonstrated otherwise: She was found to have severe disease in all of the major oxygen-carrying vessels that supplies her heart and was at a high risk for a fatal heart attack without surgical intervention. While caring for Ms. A overnight, I made the incorrect decision to administer a cardiac medication medication error definition to treat her disease that is known to increase the risk of bleeding during surgery. Given her need for the operation, the benefit of providing this medication to safely temporize her heart condition in the short-term did not outweigh the risk of delaying the intervention that she ultimately needed. Despite the standard of care regarding this clinical scenario, I made the wrong call. The background Making a medical error is the most feared consequence of practicing medicine. From misreading lab values to doing surgery on the wrong site, any slip in clinical judgment can potentially cause serious injury or even death.  A landmark study conducted by the Institute of Medicine (IOM) demonstrated that medical errors in the U.S resulted in around 75,000 unnecessary deaths and over 1 million excess injuries each year. Despite this data, it is remarkable that medical errors are made every day and usually result in little to no negative patient outcomes. Whether one is just starting out as a physician in medical training or is a leader in their respective field, all medical providers will make mistakes during their careers. Gi
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therapy or failing to receive it as prescribed or intended. Medication errors happen for many reasons. However, failing to follow the six http://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration-1/equipment/error.html rights of medication administration is probably the most basic cause. Whether http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/PerspectivesTheMistakePart1.aspx or not the patient was harmed or had an adverse reaction as a result of the error, all medication errors must be reported, not only for patient safety but for quality-improvement purposes. When you or a colleague makes a medication error, the patient’s medication error safety and well-being are your first priority. Monitor the patient closely and notify the provider and your nurse manager as soon as possible. Once the patient is stable, the person who made the error must complete an incident, variance, or quality-assurance report as soon as possible, but generally within 24 hours of the incident. The medication error in report should include the following information and any additional information required by facility policy: patient information, the location and time of the incident, a description of what happened and what was done about it, the condition of the patient, and the nurse’s signature. The incident report does not become a permanent part of the patient’s medical record; do not mention it in your documentation on the patient’s chart. The intent of this is not to hide the fact that an error occurred, but to protect the nurse and the facility. Depending on the error that occurred and the outcome, the facility may be required to report the incident to the Joint Commission. Nurses should feel comfortable reporting a medication error and not fear disciplinary action. Incident reports should not be used for disciplinary purposes but to improve systems and processes. Managers who use incident reports for disciplinary purposes run the risk of increased failure to report errors and of the same mistakes bein
Commands Skip to main content This site is best viewed with Internet Explorer version 8 or greater. Check your browser compatibility mode if you are using Internet Explorer version 8 or greater. Log In / Register Extranet Newsletter Sign Up Newsletter Sign Up close Sign up for IHI's Email Services updating ... Blog Careers IHI Home Overview Online Courses Community Project-Based Learning Home Overview Online Courses Courses Overview First-Time Visitors Return to MY COURSES Subscription Options Certificates & CEUS Curriculum Integration Activities Library Community Community Overview Chapter Network Faculty Network Blog Activities & Exercises Newsletter Sign Up Project-Based Learning Experiential Learning Overview Leadership & Organizing Quality Improvement in Action Home / Education / IHI Open School / Activities / Activities / Learning from Medical Errors (Part 1) Audio and Video Activities Activities Video Library Case Studies Games and Exercises Patient Stories Publishing Your Work Other Resources IHI LR Wide Learning from Medical Errors (Part 1) Page ContentLucian Leape, MD,Adjunct Professor of Health Policy at the Harvard School of Public Health; Kathy Duncan, RN, 5 Million Lives Campaign Faculty, Institute for Healthcare Improvement; Michael Leonard, MD, Physician Leader for Patient Safety, Kaiser Permanente Learning Objectives: At the end of this activity, you will be able to: Give examples of errors that clinicians have made in their patients’ care. Discuss the range of feelings providers can have in the aftermath of a medical error. List factors that contribute to errors in the medical setting. Description: A patient suffers horrible burns. An operation takes twice as long as it should. A child dies from internal bleeding. Errors like these, unfortunately, still happen in health care. What is one error that you’ve made? What did you learn from it? What can others learn from it? In this video, prominent clinicians describe the errors that still haunt them today — and point out ways those errors could have been prevented. Learning from Medical Errors (Part 1) Silverlight web part for playing Audio and Video files Having trouble viewing our videos? Check us out on YouTube. Discussion Questions: What is an error you (or someone yo