Mediaction Error And Fear
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Medication Error Reporting Procedure
service of the National Library of Medicine, National Institutes of Health.Hughes disclosure of medical errors to patients RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US);
Medical Error Reporting System
2008 Apr. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Show detailsHughes RG, editor.Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.ContentsSearch term < PrevNext > Chapter 35Error Reporting and DisclosureZane Robinson Wolf; Ronda G. Hughes.Author InformationZane medication error what to do after Robinson Wolf;1 Ronda G. Hughes.21 Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., dean and professor, La Salle University School of Nursing and Health Sciences. E-mail: ude.ellasal@flow2 Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: vog.shh.qrha@sehguH.adnoRBackgroundThis chapter examines reporting of health care errors (e.g., verbal, written, or other form of communication and/or recording of near miss and patient safety events that generally involves some form of reporting system) and these events’ disclosure (e.g., communication of errors to patients and their families), including the ethical aspects of error-reporting mechanisms. The potential benefits of intrainstitutional and Web-based databases might assist nurses and other providers to prevent similar hazards and impr
Health Care Clinical eLearning ClinicalKey for Nursing Additional Elsevier Resources Blog Resources Whitepapers Videos Podcasts Webinars & Events Mosby's Heritage Contact e-Commerce store Request Demo Home \ Connect Blog \ Culture of Safety Reduces Medication Errors September 20, 2011 Culture of Safety
Consequences Of Medication Errors For Nurses
Reduces Medication Errors A decade ago, the Institute of Medicine (IOM) reported that up
Ethical And Legal Implications Of Disclosure And Nondisclosure Of Medication Errors
to 98,000 patients died needlessly every year because of preventable medical errors. The report estimated the cost of these errors at $17 what is a systems approach to addressing error? billion to $29 billion a year. Medication errors, in particular, accounted for a significant portion of the errors. By some estimates, 1.5 million preventable medication errors cost hospitals up to $3.5 billion a year. More https://www.ncbi.nlm.nih.gov/books/NBK2652/ than 25,000 drug errors reportedly resulted just from look-alike and sound-alike drugs during a 4-year span. To help reduce errors and promote safety, The Joint Commission rolled out its National Patient Safety Goals program in 2002. This program was designed to help organizations address specific concerns regarding patient safety. For example, Patient Safety Goal 3 focuses on improving the safety of using medications. It mandates that healthcare organizations review a http://www.confidenceconnected.com/blog/2011/09/20/culture_of_safety_reduces_medication_errors/ list of look-alike and sound-alike medications and act to prevent mix-ups. It also expects organizations to label all medications and containers and to reduce the harm associated with anticoagulant therapy.Patient Safety Goal 8, medication reconciliation, will address ways to ensure that medications are not overlooked when patients move between the home and healthcare facilities. Down with Blame, Up with Safety To meet the challenges of reducing medical errors and promoting safe medication administration, many organizations are making a paradigm shift from a culture of error and blame to a culture of safety. In the past, facilities hesitated to disclose errors for fear of litigation. They took a “blame and shame” approach toward the healthcare professionals involved and held them personally accountable despite the fact that many patient safety problems are systems-based and beyond any individual’s control. Fear of disciplinary action was expected to maintain safety, but the same fear prevented many errors from being reported. This culture of error and blame became self-defeating: Errors were underreported, so the facilities had no opportunity to review them and improve on existing systems. To push past this culture of error, healthcare organizations have begun to openly disclose and evaluate errors in a culture of safety. With this new approach, healthcare professionals can
More Columns » Contract Language Ethics Forum In the Courts Practice Management Technically Speaking » More Listings Issue dates Regions Columns Archives Writers Help RSS Mobile Search tips Subscribe Staff directory Advertising http://www.amednews.com/article/20120220/profession/302209938/2/ Reprints Site guide Useful links About Contact Partner Links AMA Wire CPT http://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration-1/equipment/error.html JAMA JAMA Network news@JAMA Virtual Mentor Physician jobs profession Fear of punitive response to hospital errors lingers ■ Most health professionals remain reluctant to discuss problems or report mistakes freely, despite appeals to hospitals that they stop pointing fingers when things go wrong. By -- Posted Feb. 20, 2012 Print| medication error Email| Respond| Reprints| Like | Share | Tweet WITH THIS STORY: » Hospitals get poor marks on handoffs and workload » External links For more than a decade, patient safety leaders have urged medicine to shift from an approach that shames and blames individual doctors and nurses for medical errors to a "culture of safety" where open discussion and reporting about adverse of medication errors events, mistakes, disruptive behavior and unsafe conditions are prized rather than punished.This less-punitive model of medical-error prevention, inspired by the aviation industry's safety record since the 1980s, is a key element of the Joint Commission requirements hospitals must follow to get paid by Medicare. And a growing body of evidence is showing that higher safety culture scores are correlated with better clinical outcomes and lower rates of hospital-acquired conditions.Yet data released in February by the Agency for Healthcare Research and Quality show that most physicians, nurses, pharmacists and other health professionals working in hospitals believe their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what's gone wrong.Half of the nearly 600,000 staffers surveyed at more than 1,110 hospitals nationwide said they believe their mistakes are held against them, and 54% said that when an adverse event is reported, "it feels like the person is being written up, not the problem."Nearly two-thirds said they worry that mistakes are being held in their personnel file. A little less than half of respondents s
therapy or failing to receive it as prescribed or intended. Medication errors happen for many reasons. However, failing to follow the six rights of medication administration is probably the most basic cause. Whether 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 patients 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 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 nurses signature. The incident report does not become a permanent part of the patients medical record; do not mention it in your documentation on the patients 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 being made again and again. Medication incident report form References Bentz, P. M., & Ellis, J. R. (2007). Modules for basic nursing skills (7th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 828. Duell, D. J., Martin, B. C., & Smith, S. F. (2004). Clinical nursing skills: Basic to advanced skills (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc. pp. 518-519.