Identify a common error in healthcare delivery and work through Reason’s Swiss Cheese Model

Identify a common error in healthcare delivery and work through Reason’s Swiss Cheese Model, identifying how the holes can occur and what layers of protection should stop the error from getting to the patient.

Identify a common error in healthcare delivery and work through Reason’s Swiss Cheese Model

Firstly, identify a common error in healthcare delivery and work through Reason’s Swiss Cheese Model, identifying how the holes can occur and what layers of protection should stop the error from getting to the patient.

Secondly, how has the code of silence changed over the past few years? Is it more or less prevalent?

Discuss how public reporting of the HCAHPS survey will create incentives for both hospitals and nurses to improve quality of care.

VIDEO: https://www.youtube.com/watch?v=Lu-HcylvuU8&feature=youtu.be

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MEDICATION ERRORS: AN OBSTACLE TO PATIENT SAFETY

All healthcare professionals strive to provide the safest care possible. Sometimes however, things can go wrong, and harm can be done. As an Emergency Physician for more than 30 years. I have seen many healthcare workers, especially clinicians. Suffer from the guilt and embarrassment when their patients experience adverse reactions from preventable medication errors.

Medication errors are preventable human errors, and they are costly.

Each year in the U.S., severe preventable medication errors occur in close to 4 million inpatient admissions and 3.3 million of outpatient visits. A grossly inappropriate 7,000 patients die from preventable medication errors in the U.S. each year, as recorded in the report To Err Is Human.

Medication errors cost a total of $21 billion expenditure every year.

In many cases, looking back at the medication errors hardly goes beyond a comment that “he/she was busy or distracted”. Similarly, looking forward past the events does not raise more than “be more careful next time”.

The truth is, we should not blame the healthcare workers have made the medication errors.

We should look at from a broader perspective of how the medication errors happened, and in this case, the healthcare system.

 

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