Factors that negatively impact safety in a healthcare organization In the video, Chasing Zero (Denham, 2010), mentioned several factors or challenges that adversely impact patient and negatively impact a culture of safety. These factors include communication, fear, manufactured products, environment, and the healthcare system. Dennis Quaid started off in the video explaining his incident when his baby twins received 10,000 units per millimeters of heparin, instead of 10 units per milliliters. According to an article in LA Times (Ornstein, 2007), the hospital staff lacked on following the facilitys policy on verifying drug's concentration, therefore leading to an unsafe administration of the overdose. According to the article heparin was the most frequent and misused drug in the nation (Ornstein, 2007). This was partly due to the manufactured products of the 10,000 unit and 10 units of heparin vials having a similar look. Because of Quaids incident, he was able to raise awareness on healthcare safety and take action, where now heparin comes with a safety tear off red tag. One story in the video, Steven Rel, a father experienced the death of his son at his home, hours after a minor surgery (as cited in Dehnam, 2010). He did not get any information nor the hospital and caregivers reached . It had to take over a year and a lawyer to get the information about what caused the adverse event of his son. This made the patients family feel that their son did not mean anything to them or anybody. In this story, there is a block of communication to the family which eventually ended up the family seek out legal actions. By stopping all communication to family the hospital showed fear; fear of losing or owing money and their reputation. Overall families, power Running head: CHASING ZERO 3
of attorney, and patients themselves should be aware of procedures, conditions that had cause or a potential adverse event in a timely manner. In another story, Sue Sheridan experienced a similar incident in which safety in the system failed, when her husbands malignant tumor was reported unnoticed (as cited in Denhan, 2010). The final pathologist report appeared to be on file, but for some reason no one could see it except for the pathologist. There was the factor of system failure and communication. The system failed because possibly everything wasnt check. The checklist was not completed and some points were skipped. This misshaped led Mr. Sheridans life in jeopardy. Another factor is the environment and surroundings that influence the system the health-care workers work. It was noted in the video that mistakes are kept swept under the rug. Nobody wanted to move forward with mistakes because of the fear of being punished. It was mentioned by Carol Chancy MD, that sometimes people are punish tremendously when they acknowledge mistakes. She continues by mention that staff may see this punishment and want to keep any errors quiet (as cited in Denham, 2010). This brings a vicious cycle, where errors can continue to happen. By keeping mistakes or errors swept under rug avoids not fixing the system. As mentioned in the video when people see the punishment the system continues to be broken and not safe.
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Positive actions or steps that can be used to decrease or prevent medical errors or improve patient safety According to the video, one of the positive actions to start with to decrease or prevent medical error is leadership. The video stated, Great leaders take risk, confront their fear to drive adopt for best practices to make it safe (Denham, 2010). Leaders start from their errors and determining multiple factors to why the error happened. Leaders help provide evidence base practice and promote research and do their own research. Leaders can start taking action and adopting actions on improving patient safety. One of the things leaders do is take part of a major goal and bring in a motivated team in implementing increase quality care. For example in the video mentioned the 100,000 lives campaign. This campaigns goal was to save 100,000 lives by implementing safe practices. Leaders need a motivated team, where everyone can work together. Not just the healthcare staff, as well as everyone including housekeeping. Another part take in steps to improve patient safety is participating and following useful resources mentioned in the video like the National Quality Forum (NQF) and TMIT (Denham, 2010). These resources provide evidence-based practice for healthcare safety. The resource gives for health care facilities guideline and procedures that know tha work in providing quality and safe care. Another way to provide increase safety in the healthcare is to invest in technology. The video provided technology such as the Computerized physician order entry (CPOE) flight simulator (Denham, 20120). The simulator computerized system is a way for physicians can test out prior to using on real life patients. This system helps Running head: CHASING ZERO 5
provides a safety working by having error-checking such as on medication dosages, routes, or reaction. Like the CPOE, many hospitals are also adapting in the barcode scan. This is another computerized system that helps checks the right patient and provides a safety gate on administering medication. Technology can be the one of the safety tool that provides a checklist or steps on increase safer care. Often nurses give report to each other at the nurses station. In Chasing Zero (Denham, 2010), giving report off to the next nurse while in the patients room is another method mentioned in the video to improve patient safety. There, the on coming nurse can get a look at what the patient looks like, what current signs and symptoms they are showing, what they are attached to and get an overall better clear picture and report.
References
Denham, C. (Excecutive producer). (2010). Chasing zero: Winning the war on healthcare harm Retrieved from http://QSEN.org Ornstein, C. "Dennis Quaid files suit over drug mishap." Los Angeles Times 5 Dec. 2007: 1-3. Dennis Quaid files suit over drug mishap . Web. 12 Jan. 2014. <http://www.latimes.com/entertainment/news/celebrity/la-me- quaid5dec05,0,2114752.story#axzz2qVXR4nLx>