Medication error in hospital ppt,prevention of diabetic blindness,healthy blood sugar levels type 2 diabetes - PDF Review


As part of my learning on assessments in health care, I’ve come across some interesting statistics on errors in UK hospitals by the Medical and Healthcare Products Regulatory Agency (MHRA).
The root cause of errors may vary in other contexts, but it’s very interesting to see this data and I suspect that these six areas are common causes for error in many organizations, even if the percentages vary. For errors that happen where procedural steps are omitted, an observational assessment is an effective, pro-active solution. What about the other 34% of errors that arise from concentration failures, rushing and poor communication, I am sure there are ways in which assessment can help and would welcome your comments and ideas. Use these free clip art images for your collections, school projects, website art and more.
FIGURE 64-16 · A basic intravenous (IV) setup includes tubing to deliver basic IV fluids via the client’s venous access. Following the physician’s order and using a second infusion bottle or bag, the pharmacist adds medication to a predetermined volume (usually, 50 or 100 mL) of a compatible IV solution.
The controller or pump can be programmed to deliver the volume contained in the secondary bag. Nursing Alert If a pump or controller is not used, the drip rate must be calculated (see Box 64-2).
Key Concept Do not refer to a medication as an IV push if it is to be given over a period of time. FIGURE 64-18 · The nurse will often be expected to gather materials and equipment for venipuncture (phlebotomy). Venipuncture or phlebotomy is the process of puncturing a vein for the purpose of obtaining a blood specimen (“drawing blood”) or establishing an intravenous access site (Fig.
A blood specimen can also be obtained by a skin puncture (capillary puncture), as in blood sugar testing for persons with diabetes. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. They have a system called SABRE which collects and analyzes errors in hospitals relating to serious adverse reactions in the area of blood transfusions and handling.
Taking things beyond the MHRA data (and without any MHRA endorsement), I am wondering where assessments can help reduce errors.
Perhaps the training covers the area but the employee didn’t understand it properly, can’t remember or cannot apply the training on the job. Competencies or tasks needed in the real world aren’t part of the training or the post-training assessment. See Observational Assessments—why and how for more on this, or see my earlier post in this series on competency testing in health care. If you interesting in "Patient Safety" powerpoint themes, you can download to use this powerpoint template for your own presentation template.


If you can't find the clipart your looking for then please do not hesitate to get in touch and we will gladly help. Also shown are the access port on the tubing, used for injection of small amounts of medication by syringe (below) and the access port used for piggyback administration of larger amounts of medication (above).
This smaller infusion, which contains medication, commonly an antibiotic, is referred to as the secondary infusion, superimposed infusion, or IVPB. When the total contents of the secondary bag have been administered to the client, the controller or pump automatically switches back to the primary infusion bag. In this case, identify the procedure as "an IV to be given over 5 minutes or over 10 minutes,” for example. Some of the items needed to obtain a blood specimen are shown here (clockwise, from bottom left): tourniquet, Vacutainer (vacuum) blood tubes, safety syringe with needle, alcohol sponges, and gloves.
It consists of a disposable plastic sleeve into which a double-ended needle setup is inserted.
In addition, an arterial puncture can be performed to obtain values, such as blood gas analysis. In addition to the butterfly needle, two types of intracatheters are commonly used, allowing fluid to flow through a flexible catheter into the vein. Hospitals are encouraged to report errors so that better practice can be identified, and the MHRA gathered 788 human errors in 2011. Job task analysis, using surveys to ask practitioners what really happens in a role, is a great way to correct this. For viewing only, you can play with our flash based presentation viewer instead of downloading the ppt file. This method of administration is referred to as “IV piggyback” (IVPB) or a superimposed infusion. The IVPB is connected to the primary infusion by way of secondary tubing and a needle or needleless setup. The secondary bag must be hung higher than the primary bag to allow a greater force of gravity to act on the secondary solution.
This bag is hung on an IV pole and a volume-control device, such as the Buretrol, is hung below it. This pump is able to identify dosing limits and has other safeguards to protect the client. Shown also is a butterfly needle pack with a needleless Vacutainer adaptor; used to puncture a Vacutainer blood tube. This device has a needleless connector on one end and a venipuncture needle on the other end.
It is up to the nurse to reassure the client and make him or her as comfortable as possible.


See Doug Peterson’s article in this blog or mine on Job Task Analysis in Questionmark for more on this. It may also be called a small-volume parenteral delivery system, a partial fill, or a minibottle. In Practice: Nursing Procedure 64-10 describes the process of piggyback administration of medications. After priming the tubing, the ordered amount of diluent is run into the volume-control chamber (usually from 25-250 mL).
Also needed are 2 X 2 gauze squares and tape or a Band-Aid, identification stickers, and a red biohazard bag. The blood specimen can yield valuable information regarding the client’s nutritional, metabolic, hematologic, immune, and biochemical status.
The needleless end is screwed into the plastic sleeve, with the needle outward and the needleless access device inside the sleeve. They also reduce the forgetting curve and can be used to give scenarios or problems that check if people can apply the training to everyday situations.
Many facilities have firm policies regarding which medications may be given by IV push,because the push introduces a concentrated dose of medication directly into the circulatory system.
The needle end for blood drawing often contains an articulated shield, which is pushed over the needle after the venipuncture (see Fig. Both of these devices today have a locking guard mechanism that locks the needle guard in place, to prevent needle sticks when the catheter is in place and when it is removed.
This procedure is presented in In Practice: Nursing Procedure 64-12, although it is highly recommended that the nurse receive specific inservice education before performing the procedure.
This type of pump is able to identify dosing limits and other factors to aid in safe administration (Fig.
One disadvantage of the Vacutainer needle with the articulated shield is that this system contains a large needle, which might not be appropriate for some venipunctures.
In Practice: Nursing Procedure 64-11 describes and illustrates the process of using the volume-controlled administration setup.
When combined with a sensitivity test, it can identify specific antibiotics or other drugs to combat offending pathogens.
After the vein is accessed by any method, the needleless connector is pushed into a Vacutainer (vacuum) tube, which draws the blood into the tube.



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