Medication errors and nurse staffing meer,type 1 diabetes effects on pregnancy,ride to cure diabetes 2016 voetbal - Plans Download

Kimberly Hiatt, a longtime critical care nurse at Seattle Children's Hospital, committed suicide in April, seven months after accidentally overdosing a fragile baby. Stunned, she told nearby staff at the Cardiac Intensive Care Unit at Seattle Children’s Hospital what had happened. In Hiatt’s 24-year career, all of it at Seattle Children’s, dispensing 1.4 grams of calcium chloride — instead of the correct dose of 140 milligrams — was the only serious medical mistake she’d ever made, public investigation records show.
That mistake turned out to be the beginning of an unraveled life, contributing not only to the death of the child, 8-month-old Kaia Zautner, but also to Hiatt’s firing, a state nursing commission investigation — and Hiatt's suicide on April 3 at age 50. Hiatt’s dismissal — and her death — raise larger questions about the impact of errors on providers, the so-called “second victims” of medical mistakes. It’s meant to describe the twin casualties caused by a serious medical mistake: The first victim is the patient, the person hurt or killed by a preventable error — but the second victim is the person who has to live with the aftermath of making it. No question, the patients are the top concern in a nation where 1 in 7 Medicare patients experiences serious harm because of medical errors and hospital infections each year, and 180,000 patients die, according to a November 2010 study by the Department of Health and Human Services’ Office of Inspector General. That’s nearly double the 98,000 deaths attributed to preventable errors in the pivotal 2000 report “To Err is Human,” by the Institute of Medicine, which galvanized the nation's patient safety movement.
In reality, though, the doctors, nurses and other medical workers who commit errors are often traumatized as well, with reactions that range from anxiety and sleeping problems to doubt about their professional abilities — and thoughts of suicide, according to two recent studies. Surgeons who believed they made medical errors were more than three times as likely to have considered suicide as those who didn’t, according to a January survey of more nearly 8,000 participants published in the Archives of Surgery. Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. Even when they don’t think of killing themselves, medical workers who make errors are often shaken to their core, said Amy Waterman, an assistant professor of medicine at Washington University in St.
Records show that Hiatt had cared for Kaia Zautner many times since her birth, when the baby with severe heart problems was first brought to Seattle Children’s.
After the overdose, the child’s parents asked that Hiatt not care directly for their baby, but they did not appear to seek retribution, according to an investigation report by Cathie Rea, the hospital’s director of ICU. It’s not clear whether Hiatt’s mistake actually caused the death of the child, who was critically ill.
Still, Hiatt was escorted from the hospital after the mistake, immediately put on administrative leave and then fired within weeks. After the incident, Hiatt "was a wreck,” recalled Julie Stenger, 39, of Seattle, a critical care nurse who worked with Hiatt at the hospital. Officials at Seattle Children’s Hospital declined to discuss specifics about Hiatt’s termination, although they said there is “more behind Kim’s case than can be made public” because of personnel and privacy policies.
They said the hospital has since 2007 followed a so-called “Just Culture” model, which recognizes the need to use errors to identify and correct systemic problems, rather than focusing on penalizing individuals. Experts in patient safety say terminating an individual worker is rarely the answer to even the worst mistakes, unless they’re the result of repeated, willful flouting of established procedures or intentional harm.
It’s far better to identify and address the problems in the system that contributed to the error, said Mary Z.
Of those, two-thirds reported anxiety about future errors and half reported decreased job confidence and satisfaction, the study found.
There are other options to punitive actions, including education, supervision, reparations to the patient or family — and allowing the person who made the mistake to help craft specific systems to make sure it can't happen again, Scott said. In some ways, however, those who’ve made mistakes might be even safer than those who haven’t, she added.
On the day of Hiatt’s error, she admitted the mistake in a report submitted on the hospital’s electronic feedback system — and vowed not to repeat it.
A co-worker had filed a sexual harassment claim against Hiatt, who was a lesbian, in 2008, alleging Hiatt acted inappropriately by hugging her and kissing her on the cheek.
Seattle Children’s officials denied that Hiatt’s personal life had anything to do with her dismissal. Records show that Hiatt was stunned to be terminated for what she believed was a single medical error in nearly a quarter-century of service.
A storm of media attention followed news of the error, spurring state nursing commission officials to open an investigation into whether Hiatt’s license should be revoked. After fighting to keep her license, Hiatt didn’t think she’d find another position in Seattle, family members said. Faced with the prospect of not working again as a nurse, Hiatt was overcome with despair, family members said. Hiatt’s death has unleashed a storm of reaction from her family, her colleagues — and from fellow nurses. A survey of WSNA nurses in the months after Hiatt’s case became public found that half of respondents believe their mistakes will be held against them personally.
Across the country, patient safety advocates — speaking both generally and about public reports of Hiatt's case — worry that firing providers after they make mistakes leaves patients at greater risk. Officials at Seattle Children’s say armchair safety experts don’t know the details of Hiatt’s case. For Hiatt’s friends and family, all the debate in the world is useless unless it actually serves to change the circumstances that led to two tragedies: the loss of a fragile baby and the death of a nurse who loved her job. Learning to prepare and administer medications safely and accurately is an essential component of your nursing practice. Determining that you have the right drug involves checking the medication label against the medication administration record (MAR) at least three times before you administer the drug. When administering oral medications, it is sometimes necessary to give only a portion of a tablet.
If a patient is unable to swallow pills, you might have to crush a medication and mix it with food or a beverage before administering it.

Whenever you cut or crush a medication, clean the pill cutter or mortar and pestle before and after use. Medications are usually ordered to be given at certain frequencies, intervals, or times of day (such as i??hour of sleepi??).
In certain situations, medications must be administered at times other than those indicated by the facilityi??s time schedule. Accurate documentation must be available before and after a drug is administered to ensure that it is prepared and administered safely. Following the six rights of medication administration and checking the medication label against the MAR three times each time you prepare and administer a medication might seem redundant and unnecessary. The Savvy™ mobile medication workstation from Omnicell should not be confused with ordinary hospital medication carts.
This fully integrated solution features Omnicell's Anywhere RN™ software application and a wireless, medical-grade mobile workstation. The Anywhere RN software allows nurses to order medications in quieter areas away from interruptions, assisting in preventing medication errors.
Savvy provides secure transport of medications from the ADC to the point-of-care, creating a critical layer of accountability and addressing ISMP recommendations for safe transport of medications. Nurses can place all needed patient medications for a medication pass into patient-assigned locking drawers and then move from room to room, instead of returning to the ADC between each patient. Reduces trips back to the cabinet to record medication waste, which can now be done remotely. Savvy seamlessly integrates the Omnicell ADC, mobile workstation, and bedside point-of-care (BPOC) systems during the medication administration process, to enable a closed-loop process for tracking medication accountability.
Savvy is part of the Unity platform of solutions that share a single database, helping to eliminate redundant data entry that can lead to errors. Eliminates the manual process of labeling drawers: patient-specific drawers (up to 12) are automatically assigned via the software. Features independently locking drawers, which minimizes the risk of administering the wrong medication to a patient. Omnicell’s unique guiding lights technology helps nurses quickly identify the drawer that has been unlocked, adding speed and convenience to the medication administration process. Lithium-ion hot-swap battery system (2 batteries) provides up to 18 hours of continuous run time. Battery charging station conveniently charges depleted battery without having to plug the Savvy unit into a power outlet. Nurses can focus on patients without worrying about running out of power at a critical time. News Corp is a network of leading companies in the worlds of diversified media, news, education, and information services. 14, the moment she realized she’d overdosed a fragile baby with 10 times too much medication.
But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring. Louis, who studied the issue in a 2007 survey of more than 3,100 practicing doctors in the U.S.
The mistake “exacerbated cardiac dysfunction” in the baby and led to her decline, according to a statement by cardiologist Dr.
Waterman, the Washington University researcher, found that 92 percent of the doctors she surveyed said they’d experienced a near miss, a minor error or a serious error — and 57 percent confessed to a serious mistake. Although the survey focused on doctors, researchers said they believed the results could apply broadly to nurses and other health care workers as well. When harm occurs, the providers are haunted by every detail of the mistakes, often for years, said Susan D. Hospital officials said that Hiatt should have recognized that the dose was far too large for such a small child, and that Hiatt violated other dosing protocols. In a letter, Hiatt denied there was anything sexual about the action, which she said was meant to comfort the co-worker during a tough time, and described the investigation as a “witch hunt.” She said the Human Resources department had a history of discriminating against her because of her sexual orientation with one document dating to 1994. Ultimately, the agency imposed sanctions instead, including a $3,000 fine, 80 hours of new coursework on medication administration and four years of probation in which any supervisor would be required to report on Hiatt's work every 90 days. After Hiatt's firing, the Washington State Nurses Association, which represents nurses at Seattle Children's, grieved her dismissal and negotiated a confidential settlement with the hospital on her behalf. Even more worrisome, nearly a third say they would hesitate to report an error or patient safety concern because they’re afraid of retaliation or harsh discipline. They indicated they changed the way calcium chloride is dispensed in response to Hiatt’s error to make it safer, even though a state investigation found that appropriate safeguards were already in place. It requires that you follow your facilityi??s policies and procedures carefully and always implement the six rights of medication administration: the right drug, the right dose, the right route, the right time, the right patient, and the right documentation.
The exact times you perform these three checks depend on how the drug is stored and your facilityi??s policy, but in most situations you would check as you remove each drug from the storage area, as you prepare each drug, and at the patienti??s bedside before you administer each drug. However, if your facility does not have a unit-dose system or you must prepare a medication from a larger volume or a different strength, you must perform conversions and dosage calculations. It is a good practice to check with a pharmacist or a drug guide before cutting or crushing a medication. If this information is missing or the specified route is not the recommended route, notify the prescriber and ask for clarification.
Become familiar with the medications you are giving, why they are ordered for certain times, and whether or not the time schedule is flexible.
For example, a preoperative medication might be ordered to be given i??stati?? (immediately) or i??on calli?? (right before a procedure).

Medication orders should clearly state the patienti??s first and last name, the name of the drug ordered, the dose, the route, the time the drug is to be administered, and the signature of the prescriber. However, taking shortcuts and not following procedures greatly increases your chances of making a medication error. Savvy streamlines the medication administration process and provides safe and secure transportation of medications from the automated dispensing cabinet (ADC) to the patient's bedside.
Because clinicians can remotely select patient medications quickly and securely, from any location at any time, their transaction time at the ADC is reduced, providing more time for direct patient care. Nurses can use the Savvy mobile medication workstation, which integrates Omnicell's Anywhere RN software, to request, retrieve, and deliver all of their patients' medications for a medication pass with a single trip to the cabinet, without compromising on security.
Albert Wu, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. Scott, a registered nurse and patient safety director at the University of Missouri Health Care. Investigation records show that officials worried that Hiatt didn't fully recognize her role in the error. Since then, WSNA officials have heard from many nurses worried about making mistakes themselves. They say critics haven't contacted them to ask about procedures for reporting and correcting errors, or for supporting staff when mistakes occur.
In addition to checking the label against the MAR to make sure you have the right drug, check also that you have the right dose, are planning to give it by the right route, and that it is the right time.
When you are new to practice or if you rarely perform calculations or are at all unsure about the dose, have another nurse double-check your work before you give the drug. If the tablet does not break evenly, discard it, if your facilityi??s policy allows it, and cut another tablet. Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed. When giving an injection, verify that the preparation of the drug is intended for parenteral use. When medications are ordered on a PRN (as needed) basis, use your clinical judgment to determine the right time.
That hospital is among a handful in the country to have established a formal support system to help providers cope with difficult patient outcomes or errors.
30, 2010 evaluation identified her as a “leading performer,” earning a mark of 4 on a 5-point scale, records show.
Although policies differ from facility to facility, many require double-checking of doses of some medications, such as insulin and anticoagulants. If it is a controlled substance, follow your facilityi??s policy for discarding these drugs.
Because medications can alter the taste of food, avoid mixing it with the patienti??s favorite foods and beverages as this might diminish the patienti??s desire to eat or drink them. Other drugs should be given during the patienti??s waking hours to allow uninterrupted sleep. For example, when a pain medication is ordered q4-6h, assess your patienti??s pain level to determine whether your patient needs another dose after 4 hours or can comfortably wait longer.
If the patient is confused or unresponsive, your two identifiers can consist of comparing the medical record number and the birth date on the MAR with the information on the patienti??s identification band.
After you give a medication, place your initials in the designated space by the medication as soon as possible to indicate that you gave the dose.
However, state lawyers said the child’s fragile condition and poor prognosis would have made it difficult to prove legally that the overdose caused her death five days later, records show. Keep in mind that it is difficult to confirm that you are giving the correct dose after you divide a tablet, so this is a practice best avoided if at all possible. Most drug manufacturers label parenteral medications i??for injectable use onlyi?? to help prevent errors, so check the label carefully.
Most facilities recommend a time schedule for administering medications ordered at specific intervals (q4h, q6h, q8h). If your patient is a child, ask the parents or legal guardian to identify the patient, in addition to comparing the information on the MAR with the information on the patienti??s identification band. Failure to document or incorrect documentation can be considered a medication error in itself and can cause an error as well. Policies about this practice vary widely, so be sure you understand what your facility requires should this situation arise.
Most facilities also have a policy indicating how soon before or how long after the scheduled time a drug can be administered. No matter how long you have been caring for the patient or how well you know the patient, each time you enter the room to administer a medication, you must use a minimum of two identifiers to confirm that you have the right patient. Some might allow this practice only in the pharmacy, for example, or might prohibit nurses from dividing unscored tablets.
For routinely ordered medications, such as antibiotics, 30 minutes before or after the scheduled time is commonly acceptable. For example, if a medication is to be given at 0700, you can give it between 0630 and 0730 and still be administering it at the right time.

Random password generator 4 words
Bmw m logo cap
Blood sugar level of 20


  1. Azeri_Sahmar

    Translate into an elevated lack of physique fats, in contrast with the quantity plan, or it can be a food.


  2. Student

    Using mice as models showed that two.


  3. krassavitsa_iz_baku

    Research has even suggested that an extra well being.


  4. Simpaty_Alien

    Digest protein, leading to a lower net.



    Which tells you you’re full – just another however, it must be noted that snack.