Question

Select one of the three incidents among patient identification error, a medication error, and a HIPAA/privacy violation

• Consider the following analysis questions once you have selected the incident on which you will focus:
• What information do you possess about the issue? (Note: You may not be able to answer all of these questions; just include the information you know.) Consider:
  • Who was involved?
  • During what process (clinical, communication, or operational) did the issue occur?
  • When did the issue occur? During a particular shift? On a particular day? During peak hours? Under certain clinical circumstances?
  • Where did the issue occur?
• What additional data about the incident would you like to collect and analyze?
• Which best practices may not have adhered to that may have contributed to the issue? (Note: This information will prove useful to you as you complete your analysis and leadership action plan.)

TEMPLATE-TOTAL WORD COUNT 1500

Issue Summary

[Summarize the key elements of the incident that occurred. Discuss your goals in addressing the issue. Discuss 2–3 items that will be your focus. Delete all statements within brackets, such as this paragraph, and replace with your discussion. Please leave the Headings (below) in the paper.]

Culture

            [Discuss what culture is and why it is a critical organizational priority for safety and quality. Discuss what you know about the existing organizational culture (based on the knowledge you have about the selected issue). Discuss what some of the evidence-based strategies you are considering to cultivate a culture of safety.]

IHI Triple Aim

[What is the IHI Triple Aim? Discuss how the IHI Triple Aim applies to this specific incident. Describe what IHI Triple Aim elements you will incorporate into your organizational improvement strategy.]

Evidence-Based Leadership and Collaboration Strategies

[Discuss the following: Which key departments need to be directly involved with the corrective action process? What is your rationale for selecting these departments? Which specific senior leader, front-line staff member, and a clinical expert will you include in your action plan and hold accountable for implementation? What are the implications of not engaging with all departments toward making safety and quality top of mind? How might you involve other departments in addressing the specific issue and the cultural issue? Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind throughout the organization? Examples for you to consider include the chief nursing officer, the chief medical officer, the patient safety officer, et cetera. What role do you expect these leaders to play in addressing the specific issue and the issue of culture? What best practices would you employ to enlist their aid in the improvement effort?]

Leadership Action Plan

[Recommend three evidence-based actions that would help to establish a safety and quality culture. Propose three evidence-based best practices you would recommend to address the issue on an organizational level.]

Opportunities to Enlist Governing Board

[Discuss the role the governing board has in terms of quality and safety in the organization. Describe how you would enlist the governing board's aid in your improvement initiative. Discuss any additional information you could provide to the governing board to increase their involvement in the organization’s safety and quality improvement efforts.]

Conclusion

            [Summarize your analysis of the incident and your leadership action plan.]

Answer 1

MEDICATION ERRORS

Amedication error is a preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care proffessional,patient or consumer.

FACTORS CONTRIBUTING TO MEDICATION ERRORS

1. HUMAN RELATED
2. SYSTEM RELATED
3. MEDICATION RELATED

HUMAN RELATED FACTORS

PROVIDERS	PATIENTS
Over-worked	In a hurry
Under-trained	Health litracy level
Competence	Donot understand the drug use
Distracted	Trust providers to not make mistakes
illness
Stressed

SYSTEM RELATED FACTORS

• Lack of communication
• poor workflow
• Disorganized workspace
• Inadequate tools to complete work
• Lack of supervision

MEDICATION RELATED ERRORS

• Look-alike/sound-alike medications
• Multiple dosage form anf strengths

TYPES OF MEDICATION ERRORS

It includes

1. Prescribing Error
2. Dispensing Error
3. Ommision error
4. Administration error
5. Transcription error
6. Indent error

Prescribing Error

It occurs as a result of

• Incorrect Prescription
• Illegible Hand writing
• Drug allergy not identified
• Irrational combinations
• Out of list abbrevations

Dispensing Error

It is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription,including the dispencing of a medicine with inferior pharmaceutical or informational quality. It also includes,

• Dispencing incorrect medication,dosage,strength or dosage form.
• Dosage miscalculations
• Failure to identify the drugs interactions or contraindications.

Omission Errors

It is an another type of medicine error in which there is a failure to give a medication dose before the next one is scheduled.

Administration Error

It is defined as a discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber.Administration errors account for 26% to 32% of total medication errors.It involed

• Wrong patient
• Wrong route of administration
• Wrong drug
• Wrong dose
• Wrong method
• Wrong time

Transcription Error

• It is a process of making an identical copy of prescription in the medical records.
• Several sheets of paper and stages from physician's order to drug delivery may cause confusion and add to the possibility of Transcription errors.
• The contributing factors includes incomplete or illegible prescriber order,incomplete or illegible nurse handwriting,use of abrivations and lack of familarity with the drug names.

Indent Error

It occurs during the process of indenting, which includes wrong medicine,wrong strength,wrong dose,wrong route and wrong freequency.

Stratergies to prevent the medication errors

• Ensure the rights of medication administration
• Follow proper medication reconcilition procedure
• Double check or even triple check procedures
• Have the physician or another nurse read is back
• Consider using a name alert
• Place a zero infront of the decimal point
• Document everything
• Ensure proper storage of medications for proper efficacy
• Learn the institutions medication administration policies,regulations and guidelines
• Consider having a drug guide all the time.