Question

1. Why is there not more awareness regarding unintended medical harm?

2. What is the level of public transparency on patient outcomes?

3. What are some of the barriers to decreasing medical errors?

4. What are some of the solutions to decreasing medical errors?

5. List publicly available website that reports out on medical errors. Describe the information the site provides.

Answer 1

Ans 1. According to Reason, error is not meaningful without the consideration of intention. That is, it has no meaning when applied to unintentional behaviors because errors depend on two kinds of failure, either actions do not go as intended or the intended action is not the correct one. In the first case, the desired outcome may or may not be achieved; in the second case, the desired outcome cannot be achieved.

Ans 2. quality transparency, outcome information must be publicly useful, not simply available. Health outcomes are complex, requiring statistical summaries and statistical risk adjustment to enable comparisons.

Second, gaining significant benefits from improved quality transparency requires targeting. The reason is that quality information has the potential to affect choices by certain patients more than others. For example, such information is less likely to alter decisions by emergent, older, or rural patients with fewer hospital options than elective, younger, and urban patients with many hospital options. By deliberately targeting public reporting efforts at segments of the population whose decisions are most likely to be influenced by better information, policy makers can achieve greater impact on patient outcomes for a given budget.

Third, public reporting needs to be supplemented with other policy interventions. Previous efforts to improve quality transparency may have been undermined by their lack of accompaniment by mechanisms to overcome barriers to selecting the best provider. For example, without some form of travel subsidy, patients may choose a nearby hospital instead of a superior hospital.

These three enhancements to public reporting initiatives are aimed at changing patient behavior—and, hence, patient outcomes—in the short term. But public reporting can also impact provider behavior over the intermediate and long term, and lead to even greater health benefits. In the simplest mechanism, by better aligning patient choice with outcome quality, public reporting provides incentives for providers to focus strategically on their strengths and/or make investments to improve their weaknesses. However, not all long-term benefits from increased quality transparency can be obtained by market forces. The well-known “learning by doing” mechanism, which leads to a positive correlation between patient volume and outcome quality (i.e., “volume-outcome effect”), creates a tension between short-term patient utility and long-term societal utility.

Ans 3.- Keep your health care team informed.

-Make sure that all of your doctors know what medicine you take. This includes prescriptions and over-the-counter drugs, as well as supplements, vitamins, and herbs. At least once a year, bring all of your medicines with you to your doctor.

Make sure your doctor knows about all allergies you have. This includes if you have had adverse reactions to certain medicines. This can help you avoid getting a medicine that can harm you.

Make sure that all health professionals involved in your care have important health information about you. Do not assume that everyone knows everything they need to.

Ask to get information about your medicines in terms you can understand.

Ask for this information both when your medicines are prescribed and when you receive them.

Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared. This way, you know what problems to look for and can get help, if needed. Make sure you know if you should call the doctor or get emergency care.

Ask for a list of ingredients in the medicine. You should check this for possible allergies.

When your doctor writes a prescription, make sure you can read it. This prevents errors in getting the wrong medicine.

Talk to your pharmacist : When you pick up medicine from the pharmacy, confirm that your doctor prescribed it.

Medicine labels can be hard to understand. Ask questions about the directions. For example, ask if “4 doses daily” means taking a dose every 6 hours around the clock or just during regular waking hours.

Ask your pharmacist for the best device to measure your liquid medicine. Ask questions if you are not sure how to use it.

Prevent errors in the hospital : If you can, choose a hospital at which many patients have the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a lot of practice with their condition.

Make sure all health care workers who have direct contact with you wash their hands. Hand washing is an important way to prevent the spread of infections.

Before surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. This can prevent errors and confusion during and after surgery.

When you get discharged from the hospital, ask your doctor to explain the treatment plan you will use at home. This includes learning about your medicines and knowing when you can return to normal life.

Take charge of your health care : Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.

Make sure that someone, such as your primary doctor, is in charge of your care. This is especially important if you have several, ongoing health problems.

Ask a family member or friend to support your health. They can help keep track of things and speak up for you if you can’t. Even if you think you don’t need help now, you might need it later

Gather as much information as you can from your doctor. In some cases, you may want to get a second opinion. You can do research on your own as well to make sure you understand your problems and options.

Know that “more” is not always better. Find out why you need a test or treatment and how it can help you. You could be better off without it. If you have a test, don’t assume that no news is good news. Follow up to get the results.

Ans 4. It is important for all nurses to become familiar with various strategies to prevent or reduce the likelihood of medication errors.

Ensure the five rights of medication administration:

Follow proper medication reconciliation procedures :

Institutions must have mechanisms in place for medication reconciliation when transferring a patient from one institution to the next or from one unit to the next in the same institution. Review and verify each medication for the correct patient, correct medication, correct dosage, correct route, and correct time against the transfer orders, or medications listed on the transfer documents. Nurses must compare this to the medication administration record . Often not all elements of a medication record are available for easy verification, but it is of paramount importance to verify with every possible source—including the discharging or transferring institution/unit, the patient or patient’s family, and physician—to prevent potential errors related to improper reconciliation.

Double check or even triple check procedures: This is a process whereby another nurse on the same shift or an incoming shift reviews all new orders to ensure each patient’s order is noted and transcribed correctly on the physician’s order and the medication administration record or the treatment administration record. Some institutions have a chart flag process in place to highlight charts with new orders that require order verification.

Have the physician read it back : This is a process whereby a nurse reads back an order to the prescribing physician to ensure the ordered medication is transcribed correctly. This process can also be carried out from one nurse to the next whereby a nurse reads back an order transcribed to the physician’s order form to another nurse as the MAR is reviewed to ensure accuracy.

Consider using a name alert : use name alerts to prevent similar sounding patient names from potential medication mix up. Names such as Johnson and Johnston can lead to easy confusion on the part of nursing staff, so it is for this reason that name alerts posted in front of the MAR can prevent medication errors.

- Document verification:

This includes proper medication labeling, legible documentation, or proper recording of administered medication. A lack of proper documentation for any medication can result in an error.

- Ensure proper storage of medications for proper efficacy:

Medications that should be refrigerated must be kept refrigerated to maintain efficacy, and similarly, medications that should be kept at room temperature should be stored accordingly.

- Consider having a drug guide available at all times:

Whether it’s print or electronic is a matter of personal preference, but both are equally valuable in providing important information on most categories of medication, including: trade and generic names, therapeutic class, drug-to-drug interactions, dosing, nursing considerations, side effects/adverse reactions, and drug cautionaries such as “do not crush, or give with meals.

As the per guidlines attempted only 4 question .