Npsa Patient Safety Report

Defining the problems, exploring the causes and employing various research organizations to compile and address the potential causes (Berenson et al., 2014). The Advanced Nurse Practitioner (ANP) such as Clinical Nurse Leaders (CNLs) are educated in clinical research and incorporation of evidence based practices. Centers for Medicaid and Medicare Services (CMS) partnership with Patient Safety Organizations (PSOS). These organizations were to promote non-punitive reporting of safety related errors in healthcare. To date only 30 states are using these and little documentation and data gathering has explained their effectiveness on patient safety outcomes (Berenson et al.,

The documentary “Chasing Zero” reflects on the importance of quality care and patient safety. From the video, a child presents with jaundice, but the hospital fails to recognize immediate treatment. As a result, the child develops further complications such Kernicterus, which results in brain damage from jaundice (Quality and Safety Education for Nurses, 2014). Unfortunately, there were many devastating instances such as this, which could have been greatly prevented.

To create an environment where these errors are a rare occurrence, all healthcare professionals must dedicate themselves to implementing QSEN's six core competencies each and every day. These professionals must also speak up when they see room for improvement in their workplace. Regardless of the healthcare setting or demographic of patients, safe outcomes are the purpose of providing patient-centered care. Since nurses are the largest subgroup of healthcare professionals, their ability to make strides towards improved medication administration is undeniable. As the nursing code of ethics states, nurses have the duty to protect the health and safety of those in their care (Winland-Brown, Lachman, O'Connor Swanson, 2015). By taking extra caution to administer medications correctly, this honorable obligation will always be within

During my clinical day three, I demonstrated entry-level competence in professional nursing practice in caring for patients with multiple and/or complex unmet human needs. I addressed safety needs, safety in medication administration, effective communication, and surveillance for my patients. First, I addressed safety needs my ensuring the appropriate safety measures were implemented for the patients. Some of the safety measures included, wearing non-skid socks, wearing a yellow armband which indicated fall risk, keeping the bed in lowest position, two side rails up, bed locked, and the call light within reach.

Härkänen, M., Voutilainen, A., Turunen, E., & Vehviläinen-Julkunen, K. (2016). Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses. Nurse Education Today, 41, 36–43. doi:10.1016/j.nedt.2016.03.017

Quality improvement efforts and risk management are complementary, and together are key modules of clinical governance. Risk management reinforces quality management in healthcare. This leads to:

Safety provi¬sions are interpreted to protect patients from illnesses caused in the course of medical treatment as well as to provide hygienic and injury-free experience in the health care setting. Special provisions exist for safety in pharmaceuticals, blood supply, infectious disease treatment and diagnostics, and mental health services, among others. Ethical codes for doctors, nurses, and other health care workers contain provisions applicable to the patients’ right to safety. Medical errors and other actions that fail to meet safety standards can carry civil, criminal and administrative penalties

The guidelines set up within the Nursing Process for Medication Safety are established to prevent errors, to prevent harm, or promote a therapeutic response. It is a nurse 's responsibility to adhere by these guidelines no matter what. However, if a nurse works outside the guidelines that are set for administering medication safely, he/she takes it upon themselves to abide by the legal consequences that the laws have in place for negligent nurses in healthcare. Nurses play the most valuable role when it comes to medication error prevention because nurses serve as the gatekeeper to medication administration. Kim Maryniak said it best when she implied, “As nurses, we are often the last “gatekeeper” in the administration process to prevent medication errors. It is important to take the time needed to ensure patient safety, and to minimize distractions throughout the process.” (Maryniak,

A major push for the improvement of quality and safety outcomes was in 2000 when the Institute of Medicine published, To Err Is Human: Building a Safer Health System. In 2003 the Institute of Medicine (IOM) laid out the six core competencies for healthcare workers. In 2007, the Quality and Safety Education for Nurses (QSEN) project redefined the competencies to fit the care of nurses (Jones, 2013). Two of the competencies laid out in this project are quality and safety. These are often clumped together, but are in fact two separate competencies. I will be laying out what is safety and how it differs from quality. How a culture of safety needs to be a system approach and not just an individual approach. Lastly, discussing

Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ: British Medical Journal (Online), 353.

The patient is reported to have shortness of breath from initial handover between emergency department nurse to ward nurse. With the patient’s history of a chronic obstructive pulmonary disease, their level of consciousness should have been observed frequently to classify the patient had not undergone hypoxia and hypercapnia. Furthermore, evidence between two nurses from the time of 0300 hours to 0500 hours, did not comply. As the attending nurse had said she left at 0300 hours and returned at 0500 hours, the nurse left on standby said the attending nurse had, indeed, made an appearance within that time (HCCC v Jarrett, 2013, 116, 118-121).

I have work as a certified nursing assistant in the surgery unit and we have already implemented most if not all these patient safety measures. As a nurse, I will continue to practice and perform these safety measure that I have learned from my colleagues. Any patient that enters my unit will be asked to identify themselves. Patient will be asked to say their name and date of birth, while I make sure that their information is accurate on their arm band. Next step in the process, is to attain a medical history, from their current medication, health history and any allergies. This information is important because it will give an idea to how to properly care for the patient. I will be able to figure out what type of medication, for example

According to the Institute of Medicine (1999) 44,000-98,000 people die as a result of errors made in the healthcare system. System level failures and human error are often identified as causes of harm (Institute of Medicine, 1999). Patient safety is a focal point for healthcare organizations across the country (Ulrich & Kear, 2014). Many organizations strive to develop and maintain a culture of safety. According to Katz-Navon, Naveh, & Stern (2005), the health care industry struggles with minimizing or eliminating errors impacting the patients they serve. My current organization is focusing on ways to enhance patient safety and the safety climate.

Communication is described as the interchange of information, thoughts, and feelings between individuals using dialog or other methods (Kourkouta, & Papathanasiou, 2014). Communication between patients, nurses, and other healthcare professionals can influence the patient outcome subsequently, understanding what establishes an effective communication will be beneficial for nurses and other healthcare professionals. Having the skills to articulate efficiently exists beyond having verbal skills. According to Wright (2012), to establish effective communication, a nurse should develop the use of nonverbal cues such as body language, demonstrating active listening skills to facilitate assurance that the interaction remains successful, and having

The theoretical framework chosen for this study would be follow the Eindhoven model. This model was adapted by Henneman and Gawlinski (2010), investigating “near-miss” events, and conceptualize the role of the nurse at point of care in preventing adverse events and outcomes for patients. The reason for choosing this model, that it clearly demonstrates the relationship between human operator, organizational, and technical failures, because of the development of incidents that may or may not lead to adverse outcomes (Henneman et al., 2010). In the healthcare setting, if a high-risk condition is not prevented by adequate defenses system, it will not be interrupted, therefore places a threat on the patient’s safety (Henneman et al., 2010). Bedside