Loss Of Trust in The Health Care Organization

Loss Of Trust in The Health Care Organization Essay Paper

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Loss Of Trust in The Health Care Organization Essay Paper

Medication Error
Later that week, the PSO gets a call from the hospital’s risk manager.Kyra Dilley and Arthur Chester
Kyra Dilley: This is Kyra Dilley.Arthur Chester: Hi, Kyra, this is Arthur Chester. I’m calling to let you know about a medication error on the eighth floor.Kyra Dilley: Oh, no. Was it B. Moore or B.R. Moore?Arthur Chester: How did you know? It was B. Moore, birthdate 8/11/05. My investigation isn’t complete but there were two patients with similar names and birthdates in rooms in close proximity.Kyra Dilley: Okay. Have you interviewed the nurses involved yet? There should have been different nurses for each patient.Now that you’ve spoken with some non-clinical stakeholders, answer the following questions:
Question 1: Given the information about the medication error, which is the most appropriate first step for the patient safety officer to take?Your response:Incorrect.
Correct Answer: Check on the patient’s clinical status.Determining whether the medication error is an isolated event or a trending issue is an important step, but it can be performed later — during the investigation.Incorrect.

Correct Answer: Check on the patient’s clinical status.Notifying the risk manager is an important step, but it is not the first step.Correct!
Patient safety always comes first. It is the patient safety officer’s first responsibility to check on and document the patient’s clinical status.Incorrect.
Correct Answer: Check on the patient’s clinical status.Health care organizations are not required to report all errors to the regulatory agency. Additional fact finding and possibly a complete investigation need to be performed before notifying the regulatory agency. Question 2: Which of the following has the least impact on the medication error?Your response:Incorrect.
Correct Answer: Scheduling of the unit secretary.The original medication order is important to consider when investigating the error. The original order may have been transcribed incorrectly, or it may contain important information related to why the error may have occurred. For example, the original order may have been illegible, it may have requested an incorrect dose, or it may contain a look-alike or sound-alike medication.Incorrect.
Correct Answer: Scheduling of the unit secretary.Knowing which medication was administered is important to consider, because this may have a significant impact on the patient’s prognosis.Incorrect.

Correct Answer: Scheduling of the unit secretary.Staff workload and working conditions at the time of the error are important considerations in this situation. The staff may have been overwhelmed, distracted, or focused on other items, resulting in a lack of focus on this particular patient.Correct!
Whether this unit had a secretary scheduled to work at the time of the error is unlikely to have had an impact on the medication error.Question 3: The Joint Commission states all of the following about medication errors or issues EXCEPT:Your response:Correct!
The Joint Commission states that medication errors often result in adverse events.Incorrect.
Correct Answer: Although common, medication errors do not often result in adverse events.The Joint Commission requires health care organizations to conduct a root cause analysis to determine the cause of the medication error.Incorrect.
Correct Answer: Although common, medication errors do not often result in adverse events.The Joint Commission requires health care organizations to develop a corrective action plan and monitor it closely to ensure its effectiveness.Incorrect.

Correct Answer: Although common, medication errors do not often result in adverse events.The Joint Commission encourages patients and caregivers to actively participate in their health care.Question 4: From a regulatory perspective, the best resource to consult on medication errors is:Your response:Incorrect.
Correct Answer: The appropriate regulatory agency’s accreditation manual.The previous patient safety officer is not the best choice, as this individual may no longer be with the organization. Likewise, regulatory agency standards change frequently, and the previous patient safety officer’s knowledge of regulatory agency standards may be outdated.Incorrect.
Correct Answer: The appropriate regulatory agency’s accreditation manual.Previous actions the organization took in similar cases is not the best resource to consult in the case of medication errors. Each case needs to be considered as a separate event, for the conditions and specifics of each event differ, and previous actions may not apply. In addition, the organization may not have taken the best or most appropriate action on previous similar cases.Incorrect.
Correct Answer: The appropriate regulatory agency’s accreditation manual.The health care organization’s legal team is not the best resource to consult in the event of a medication error. The health care organization’s legal team represents the health care organization, not the regulatory agency.Correct!
From a regulatory perspective, the appropriate agency’s accreditation manual is the best resource to consult in the event of medication errors. This manual will provide the most current, applicable, and accurate information.Question 5: What is a medication error called when it is corrected before it occurs?Your response:Correct Response: These are called near misses.Question 6: What is a medication error called when it is corrected before it occurs but could have resulted in a patient’s death?Your response:Correct Response: These are called adverse events.Question 7: What is a medication error called when it results in the patient’s death?Your response:Correct Response: These are called never or sentinelevents.Question 8: Which of the following would be a potential consequence for the health care organization if a medication error resulted in the patient having a prolonged hospital stay?Your response:Incorrect.

Correct Answer: Increased cost to the health care organization.Patient disability would be a consequence for the patient rather than for the health care organization. However, a patient disability could be a consequence for the organization if the patient chose to pursue legal action against the organization.Correct!
An increased length of stay will result in increased costs to the organization, because it will have to care for the patient for a longer period of time than would have been necessary absent the medication error.Incorrect.
Correct Answer: Increased cost to the health care organization.An increased length of stay does not necessarily mean that a sentinel or adverse event will occur.Incorrect.
Correct Answer: Increased cost to the health care organization.An increased length of stay for a patient due to a medication error would not necessarily result in a loss of accreditation.Question 9: The two most common methods health care organizations use to encourage event reporting include: ___________ and ____________.Your response:Correct Responses: Health care experts in patient safety and quality improvement cited the following as potential implications for the organization if a mistake or adverse event occurs as the result of a patient identification error:

Loss Of Trust in The Health Care Organization Essay Paper

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