A typical patient can be connected to several devices to receive medications, fluids and nutrients. Unfortunately, these tubes can be misconnected. One example of a dangerous misconnection is when a patient received enteral feeding formula intravenously because the tubing intended for the feeding tube was connected to the IV instead. Organizations have tried different strategies to reduce the risk of these misconnections.
An EHR can help promote patient safety, but its success is
implementation-dependent. Hospital leaders conduct an assessment
of goals for technical readiness. Along with the vendor, the
hospital outlines an implementation plan. The plan is
implemented, a group of hospital staff members are trained, and
they go through a mock “go-live” and pilot test. An actual
“go-live” goes without a hitch, perhaps a few minor glitches, but
essentially, the EHR is implemented.
Julianne Morath, President/CEO of the Hospital Quality Institute
(HQI), and Rhonda Filipp, director of quality & patient safety
for CHPSO, a division of HQI, collaborated with Michael Cull of
Vanderbilt University Medical Center to develop a recent
publication for the October 2014 edition of AORN
Strategies for Enhancing Perioperative Safety: Promoting Joy and
Meaning in the Workforce. This article focuses on the
recognition of workforce safety as a precondition of patient
Medication reconciliation is intended to ensure the accuracy of the medication list at each patient encounter. However, the medication lists are entered into electronic health records by a variety of individuals (both licensed and unlicensed) across different health care settings and are not always accurate. A significant patient safety hazard may occur when these lists are used to create hospital medication orders that result in the continuation of inaccurate and/or incorrect medications.
A patient safety
evaluation system is the system you use to collect, manage, and
analyze information (patient safety work product) for reporting
to your patient safety organization, CHPSO. There is no
one-size-fits-all policy; each health care facility has needs
that others may not experience. It is important to keep in mind
that the PSES can be an evolutionary document and it is
beneficial to revisit it regularly. While most hospitals submit
all incident reports and RCAs to CHPSO, some may only report
specific event categories.