Joint Commission- National Patient Safety Goals

The following are the National Patient Safety Goals for 2016: improve the accuracy of patient identification, improve the effectiveness of communication of caregivers, improve the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk of health care- associated infections, and for the hospital to identify safety risks inherent in its patient population (Hudson 2016 page 2). Under each category there are specific goals, such

Medication Reconciliation is defined by the Joint Commission as the process of checking and rechecking a patient’s current medication list to the patient’s orders. Within a MedRec program, three steps must be followed to ensure patients have the correct medications at admission and discharge: Verification, Clarification, and Reconciliation (Greenwald et al., 2010; Ruggiero et al,. 2015). MedRec should not occur once, but multiple times especially when a patient moves from department to department. The more a patient moves, the more liable they are for a medication error due to poor communication. MedRec is done for the simple reason of catching those medication errors and correcting them before they can do any harm (The Joint Commission, 2006). Medication errors effect nearly 1.5 million people who enter the hospital setting in the USA. At least every patient has one medication discrepancy between admission and discharge, which leads to rehospitalizations due to hospital-setting medication errors (Institute of Medicine as cited by Wilson et al,. 2015). With nurses at the forefront of a patient’s medication regime, pressure is put on them to provide the necessary education and safety to prevent medication related rehospitalizations. Included in the causes for medication errors is miscommunication between departments taking care of the same patient (Allison et al., 2015). Many medication errors are preventable by the implementation of electronic orders. The use of electronic

A major concern or challenge of ABC hospital is a recent incident of medication administration error in its emergency room (ER) which almost resulted in the death of a 55-year-old female patient. This is a case of medication administration through the wrong route. The Food and Drug Administration (FDA) defines a medication error as "any 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 professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding;

As a student pharmacist, I am interested in medication errors and initiatives for their prevention. In response to the IOM’s report, the Food and Drug Administration (FDA) agency enhanced its error reduction strategies by implementing a new division dedicated to medication errors.3

In health care settings across the country patient care is compromised by various preventable mistakes. Health care workers (HCW) are continuously pushing the boundaries of time constraints. As these demands are increased the possibility for poor patient outcomes also increase. Prevention is the first line of defense and promotes healthy practices for HCW and patients. The Joint Commission (TJC) collects data pertaining to the incidences, information surrounding each case and establishes a national quality and safety standard. TJC accredits thousands of health care establishments with the goal to provide safety and increase the quality of care provided in each setting. In 2016 TJC released a new set of National Patient Safety Goals (NPSG). The goals are meant to bring awareness to the accredited facilities and HCW of concerning hazards that need to be focused on. For instance, using two identifiers when identifying a patient to prevent medical errors, and preforming hand hygiene to reduce the risk of infections.

Medication errors are a reoccurring issue that has plagued the medical field since the beginning of drug administration. In order to understand how to handle medication errors, one must first understand what a medication error is. The concept of medication error can be defined as: “any preventable event that may cause or lead to inappropriate medication use or harm to a patient” (Kee, 2012, 125). Examples of medication errors include: misreading a patient’s medical file, not clarifying illegible prescriptions, an incomplete patient assessment, confusing look-alike and sound-alike medications, and lack of better understanding if a medication can be crushed or split. To better understand medication errors and medication safety one must understand the impact it can have on the medical community and patient care, ways to prevent medication errors, and what should be done in a situation where a medication error has occurred.

Majority of errors are thought to be preventable, and multiple interventions may be required to significantly decrease medication errors, particularly when patients transition between healthcare settings.

After reviewing the 2014 Patient Safety Goals, the one that drawn my attention the most, is the Patient Identification goal. The article that I chose is Patient Safety Solutions. This article was written back in May 2007. This article is about the failure to identified patients correctly and the consequences that occur as a results. Some of the bad outcomes as a result of such failures include, patients received wrong blood transfusion, laboratory received wrong blood for different patients. There were wrong patients being operated on, and patients were given wrong medications.

Medication errors originate in multiple ways such as “professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (U.S. Food and Drug Administration, 2015). Many patients may be quick to criticize medication errors to be the responsibility of the professional who administers the medication rather than the manufacturing, production and data entry processes.

Medication errors are the most frequently identified error that occurs in healthcare settings. To minimize these potential errors the five ‘R’s were put into affect. They include, right patient, which can be done by nurses checking their patient’s wristband, or asking name and date of birth. Right drug, the

Patient safety is a growing concern among healthcare professionals and the public (Goh, Chan, & Kuziemsky, 2013). As professional nurses, it is our duty to demonstrate improved safety for our patients, visitors and guests to the facilities in which we serve. It is also our duty to prevent adverse events and to view unfortunate incidents as learning opportunities to achieve a holistic view of patient care. By improving patient safety, we accept responsibility for more positive patient outcomes and a successful hospital stay. The purpose of this paper is to analyze the importance of data evaluation and interpretation to improve patient quality and safety.

An education program over medication safety may aid in reducing medication errors and the harm that follows errors. A commonly used strategy is the “5 Rights of Medication administration” which includes right patient, right drug, right dose, right time, right route (Leape et al., 1995). Currently, this strategy has been updated to six rights, adding right documentation (Pape et al., 2005). Another option available to teach medication safety is to utilize the use of technology. For examples, employees may be required to watch several education videos before they can administer any medication. Technology is always advancing, and advanced technology may aid further in the safety of patients. For example, some institutes are implementing intravenous infusion pumps, otherwise called “smart pumps.” The pumps have software that can be managed to be specific to the hospital and patient care, and the medications, standard concentrations, dosing units, and dosing limits are configured. These pumps promote safety by alerting the nurse when she has programmed the infusion rate too low or too high (Dennison, 2007). The Food and Drug administration have also worked on reducing errors by implementing bar codes. When a patient enters the hospital, they receive a bar-code bracelet for identification and nurses use the scanner to scan the

VHA is committed to improve patient quality, and safety. In developing, and implementing the National Center for a Patient Safety (NCPS) program in 1999 for the reduction, and prevention of accidental harm to patients as a result of their care; a report brief, “To Err is Human” was published by the Institute of Medicine (IOM) which brought national attention to the problem of adverse events in health care, including the fact that these adverse events caused

This paper addressed the problem of medication errors in the healthcare setting and how they occur. Although medication errors sound harmless it actually injures hundreds of thousands of individuals a year in the United States. The significant of this subject is that medication errors occur according to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although medication errors can occur in any floor at any moment it is more prevalent to occur in the modes of transferring a patient. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.” During this time frame the patient is changes settings and, the person responsible for the health care decision is also changed. The specific clinical question guiding the search for quantitative research article is as follows: In hospitalized patients that are being transferred would proper communication decrease the risk of medication errors? The Population would be hospitalized

The clinical unit that I work in, Baystate Medical Center, has implemented a number of effective strategies to reduce the incidence of medication errors, and they scored higher than the average hospital of the same size in medication administration safety. There is a variety of safety mechanisms built into place which have helped ensure the safety of patients. These include use of an electronic medical record (EMR), computerized provider order entry (CPOE), “bedside barcoding scanning for patients and medications”, “automated dispensing cabinets”, “electronic medication reconciliation”, and ePrescribe (Prevention, n.d.). Such technology has significantly improved the way healthcare professionals provide care, and minimizes risks of medication administration errors.