1.System-Wide Safety Failures every system is perfectly designed to achieve the

Question

1.System-Wide Safety Failures every system is perfectly designed to achieve the results it gets. —Dr. Paul Batalden In the years following the publications of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, increased attention was given to mitigating the circumstances in which patient safety is compromised. Increasingly, adverse events that occur within healthcare organizations are recognized, not as the failure of any individual (health provider or patient) but as system-wide failures. High-profile sentinel events, such as Libby Zion, Josey King, and the Quaid twins, to name a few, have attracted public attention and spotlighted the tangled or missing systemic threads that can lead to serious outcomes. Likewise, in this environment, adverse events that might cause little or no harm are gaining increased attention. This shift in perspective is having a profound and ongoing impact on how healthcare is delivered, regulated, and reimbursed. Bring to mind an adverse event that has been publicized or one with which you are familiar, one for which there was a resulting systems change. With this event in mind, respond the following: Analyze the adverse safety event that became an impetus for systems changes related to patient safety as follows: Describe the event and its effects on key persons involved. (2–3 paragraphs) Explain the systemic failure that allowed the event to occur. (2–3 paragraphs) Explain system changes that were made as a result of this event as well as the outcomes of those changes. (2–3 paragraphs)

PLEASE use U.S sources and examples. Provide references

Explanation / Answer

According to The Agency for Healthcare Research and Quality medication errors "one of the most common types of inpatient errors," as nearly 5 percent of hospitalized patients are affected by adverse drug events annually.

In fact, medication errors occur in some form in nearly half of all surgeries, according to research from Massachusetts General Hospital published in October. Mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by a patient's vital signs, and documentation errors were the medication errors that occurred most frequently.

Event occurred:

A patient was ordered 20cc Kesol(oral potassium supplement) the order was verbally given by the doctor was kesol 20cc not mentioning the route type of medication .The staff was in a hurry to end her shift by mistakenly gave inj kcl 20cc which lad to sudden hyperkalemic changes in the ECG thus leading to life taking arrhythmias

Persons involved

The doctor who prescribed the order

The primary nurse who was taking care of the patient

The patient herself

Systemic failure that allowed the error

There was no policy for verbal orders and proper medication administration policies were not used due to personal or systemic negligence

System Change that was made

A verbal order policy was made in which the following rules were enlisted

·        The nurse introduces herself while answering the phone

·        The doctore introduces himself before the order

·        The nurse writes down the entire order In to the treatment sheet

·        The nurse reads out the entire order once the doctor completes the prescription

·        The doctor is supposed to come physically and write a written order within 24hours

The other change that was brought about was the introduction of high risk medication as Kcl falls into the category of fiving serious complication a policy of recongnising high risk medications was done all high risk medication administration would be counter checked by two nurses before administering

The other change that was brought about was education to all the resident doctors about the correct and complete prescription which includes the

·        Date and time of order

·        Name of the medication

·        Route of the medication

·        Dose of the medication

·        Frequency of the medication

·        Signature of the doctor

Outcome

The outcome of the following system change showed the significant fall in medication errors throughout the hospital

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