Copy of Project #2 : System Design and Error Reduction Strategies

Hi there.

Thanks for joining us.

S. Oh, my name is Sam.

Whichever. And I'm here today with Amanda Lancaster and we're

here to present on system design in air reduction strategies.

We wanted to begin today by talking about an event

summary of a procedure that had happened in the hospital.

So this began with a teenager and a Caesarian procedure.

A 16 year old patient was admitted to the hospital

to deliver her baby upon admission on infusion that was

intended exclusively for the epidural route of administration was connected

to the patient's peripheral i V line and was infused

via a pump to the patient's body.

Within a few minutes, the patient experienced cardiovascular collapse.

A Caesarian section resulted in the delivery of a healthy

infant. But the medical team is unfortunately unable to resuscitate

the mother.

Okay, arrival is when the perimeter of active failure takes

place. The young woman arrives on birthing unit around 9.

30. I am accompanied by her mother.

She arrived three hours late for her scheduled induction, and

although the time of arrival and time frame in general

is not important, the most important is that the nurse

assigned to the patient spent the first hour calming the

patient's fears about the birthing process.

So we have a factor of stress there.

The nurse began the full administration admission assessment and documentation

process around 11 o'clock AM She completed the admission profile

within an hour, but had not yet applied a bar

coded identification ban to the patient's arm.

Do you already see any Swiss cheese holes for Medicaid

and error?

The first one to discuss is the failure to apply

bar coded information to patient arm.

Um, so we're looking at the bar coded information.

We kind of wanna look about what and how this

is a latent failure.

So the less apparent failures of design that contributed to

an air are what we consider latent failures.

The latent failures air those that are on the other

end of the arrow, the blunt end, and they refer

to many system elements or deficiencies off the health care

system that lead a person to commit the air.

So specifically, looking at our bar code here, we're looking

at the admission profile completion.

We see that there was a latent air in our

case patients case, um, it claimed that she meaning The

nurse completed the admission profile within an hour but had

not yet applied a bar coded identification ban to the

patient's arm.

So this could be viewed as failure in design because

the scanning of the patients barcode should be a requirement

for closing out the admission profile for the patient to

then proceed to evaluation by a physician.

So again we can see that the admission profile was

not actually completed.

And this is indeed a latent air.

The next part I want to talk about was what

was noticed.

First, eso in this case, we're looking at what is

an active failure in a sharp end.

So in the module for lecture, it states that an

example of active failure is a nurse pushing an incorrect

button on an infusion pump.

In our patient case today, the patient, the nurse, was

being close to the patient, and they did commit the

air that involved medication bags that were unidentifiable, unidentifiable from

each other.

So this would be, um, the antibiotic and the fentanyl

use for the epidural.

They were unidentifiable well from each other in terms of

just appearance alone.

The incorrect medication was hung and it was distributed through

the patient's entire body by the ivy pump.

Next, I would like to talk about the latent failure

leading to a potential active failure.

This is when active in Layton process failures merge, creating

an intersectional point that is consistent in London.

Double check system as referenced by Smeltzer 1998 As for

a, there was no auxiliary warning labels that were placed

on the syringes or the pharmacy label to alert the

staff that penicillin six and Ben Sippin could be administered.

So now we have a comparison of cases that I

would like to make.

In this comparison of cases, I would like to compare

the assigned case study and the lesson from Colorado.

Beyond blaming individuals, I will explain the first parallel.

The nurse discontinued the piggyback solution, believing the patient's reaction

was a penicillin allergy and called for help.

The patient received between 70 mL or 20 mL and

30 mL of the epidural solution before discontinuing of the

piggyback. This is a parallel between the unclear definition of

non physician prescriptive authority assigned well, although the hospital policies

didn't clearly define the prescriptive authority of non physician nurses

and nurse practitioners, routinely prescribed medication within the scope of

their practice.

So this means that nurse practitioners began to have the

scope to prescribe medication so that this air would not

occur where you have non physicians and nurses continually having

the authority to prescribe medications that are pretty serious in

life threatening in life, altering medical situations.

Okay, so looking at the second comparison here that we're

making during the assigned case versus the Colorado beyond blaming

individuals but that during the code of our assigned case

and the subsequent uh, endotracheal intubation, the lead physician did

not notice any airway oedema.

Um, And so in the Colorado lessons, we have learned

that to prevent ares associated with drug allergies, experts actually

recommend identifying a central location of information or a single

record of truth to document the allergy information.

In our assigned patient case.

If there was a specific um, spot that they could

have looked at, such as on a barcode or immediately

notified on a patient chart of an allergy, then the

physician would have immediately recognized the patient did not have

a penicillin allergy listed, and that was not likely what

the reaction that they were seeing occur was what was

happening. The next parallel you make up.

A few minutes later, a partially infused epidural solution bag

and a unspoiled penicillin bag would have spurred it.

Will determined that the partial had the patient had received

an ivy solution a fentanyl and broke it The vary

eight. Excuse my pronunciation instead of penicillin, The patient.

I can't read that, My Todd.

Go ahead.

The patient I presumably from the cardio toxic effects of

Varick Ain.

This correlates with the drug labeling in nomenclature parameter that

is imperative to facilitate proper identification and use of medications,

product manufacturers and healthcare organizations, especially pharmacy, should ensure that

all drugs are provided in clarity labeled contain and clearly

labeled containers to promote clarity and should take state steps

to prevent Ares due to look alike drug name and

container labels as this would be a solution in this

case for this case scenario.

All right, so now that we've discussed our patient case

here, I do apologize.

It's gonna make me go through this.

Um, we could just want to go ahead and kind

of summarize a few things that we have realized from

our event.

We'd like to start off with, um, just kind of

doing a knowledge check on the things that we've learned

from this patient case.

Eso what key system elements of medication use influence the

recurrence of this event.

So we'd like to look at the options a through

e below and specifically select all that apply for this

patient scenario.

Um, so our answer for our patient case was specifically

answers A and B patient information in regards to the

fact that they never had the barcode label on their

risk to start with, as well as the nurse thinking

that it might have been a penicillin allergy as well

as the labeling, packaging and nomenclature.

Eso kind of with the confusion between how the patient

got the penicillin versus the fentanyl and just different ways

in which that could have been packaged or different, naming

in ways that we could have prevented airs along that

one. We do not believe there really any environmental factors

or drug shortages, stock standardization, distribution issues, or any device

acquisition or use monitoring.

In this case, however, we do recognize that this is

a common occurrence of medication airs within the health systems.

And lastly, we did just want to provide a summary

of our recommendations for this specific patient case and how

we prevent re occurrences from happening.

So barcode scanning needs to be completed by nurse admissions

before the patient is seen by any other medical personnel.

This should be part of the admission process and should

not be something that is scepter looked over.

Medications should have colors that clearly identify the antibiotic versus

the epidural solution in this instance, but could be expanded

upon to really any medication that could cause harm.

And pharmacy labels should be placed on syringes and I

V bags to alert the hospital staff.

The hospital staff should have staff meetings to review roles

and procedures for optimal patient care.

And we do want to ensure that patient safety should

always be our number one priority.

We also wanted to mention that hospital staff should have

continuing education programs that happen for them to know how

to handle medications that are not on the formulary.

So that way, if a situation like this does arise,

that reminded of the protocols, and that is our presentation

on system design and air reduction strategies.

Eso thank you again for listening.

My name is Sam Hatch.

Ever. And I had Amanda Lancaster here.

We're a pair.

33 per pharmacy.

Uh, 75 70.

Thank you.

Copy of Project #2 : System Design and Error Reduction Strategies

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