Get Full Essay Get access to this section to get all help you need with your essay and educational issues. The prevention of errors is the main emphasis of a RCA. The team should consist of nurses, physicians, pharmacists, therapists, hospital administrators. Once the team is assembled they should work through the RCA process.
During June-Augustpractitioners responded to an ISMP survey designed to identify which medications were most frequently considered high alert drugs by individuals and organizations.
Inthe preliminary list and survey data as well as data about preventable adverse drug events from the ISMP MERP, the Pennsylvania Patient Safety Reporting System, the FDA MedWatch database, databases from participating pharmacies, public litigation data, literature review, and a small focus group of ambulatory care pharmacists and medication safety experts were evaluated as part of a research study funded by an Agency for Healthcare Research and Quality AHRQ grant.
This list of drugs and drug categories reflects the collective thinking of all who provided input. Establish a check system where one nurse prepares the dose and another nurse reviews it.
Do not store insulin and heparin near each other. Spell out the word unit instead of using the abbreviation U.
Build in an independent check system for infusion pump rates and concentration settings. Limit the opiates and narcotics available in floor stock. Educate staff about hydromorphone and morphine. Implement PCA protocols that include double checks of the drug, pump settings, and dosage.
Remove concentrated KCL from floor stock. Move the drug preparation off the units and use commercially available premixed IV solutions. Standardize and limit drug concentrations. Standardize concentrations and use premixed solutions. Use only single-dose containers. Remove heparin from the top of medication carts.
Sodium Chloride Solutions Concentration above 0. Remove sodium Chloride concentration solutions above 0.
Double check pump rate, drug concentration and line attachments. The anticoagulants most commonly used and most frequently involved in medication error are unfractionated heparin, warfarin and enoxaparin. Contributing factors to medication error with the use of anticoagulants include Inadequate screening of patients for contraindications and drug interactions.
Lack of standardized naming, labeling and packaging Keeping up the changes to the different dosing regimens, drug interactions and reversal agents is difficult, particularly for practitioner who not routinely prescribe anticoagulants Failure to document or communicate individualized instructions and current lab results during hand-offs Pediatric administration errors because anticoagulants are formulated and packaged for adults, Risk reduction strategies Improve staff communication and information access Involve the patient in the management of anticoagulation therapy Implement a pharmacist managed anticoagulation service Use computerized provider order entry or barcoding technology Other JCAHO recommendations Perform an organizational-wide risk assessment for anticoagulant therapy.
Use best practices or evidence-based guidelines regarding the use of anticoagulants. Establish organization-wide dose limits on anticoagulants and screen all orders for exceptions i. Clearly label or otherwise differentiate syringes and other containers used for anticoagulant drugs.
Clarify all anticoagulant dosing for pediatric patients.A root cause analysis (RCA) is the direct application of quality improvement principles and methods focused on uncovering system and process deficiencies that lead to care failures (Werner, ). A patient who dies from acute respiratory failure after a procedure involving moderate sedation is cause enough to first investigate the reasons.
Define Root Cause Analysis, For example, frequent monitoring instituted for conscious sedation procedures does not reduce the risk of the sedation being too deep. However, it allows early intervention to reverse the sedation and provide adequate oxygenation.
Medical errors are fostered by intimidating and disruptive behaviors. Left. May/June Staff Leadership Key to Enhancing the Root Cause Analysis Process: Root cause analysis team leaders and teams organized at the Charles George VA Medical Center, Asheville, N.C., include a diverse group of staff members, in an effort to promote the idea that patient safety is .
Organizational Systems and Quality Leadership Essay Sample. A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led .
Moderate Sedation (Conscious Sedation) II. Policy A. sedation assessment includes but is not limited to: 1. Physical status assessment (review of systems, vital signs, airway, cardiopulmonary reserve, past and present drug history including drug allergies); 2.
Previous adverse experience with sedation and analgesia, as well as with regional and. The Root Cause Analysis. Causative factors- (why it happened) determined cause. Individual’s cause factors. Nurse J did not follow procedure for conscious sedation.
The patient was not placed on continuous B/P, ECG, and pulse oximeter throughout the procedure. Respiratory Therapist was not informed of the conscious sedation.