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The document discusses the 2012 Joint Commission National Patient Safety Goals. It provides 3 goals: 1) improve patient identification, 2) improve communication among caregivers, and 3) improve safety of medication use. It also presents several case studies on medication errors and discusses root causes, prevention strategies, and recommendations to reduce errors.

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2012 Joint Commission National Patient Safety Goals ,[object Object],[object Object]
Joint Commission Patient Safety 2012 ,[object Object],[object Object],[object Object]
2012 National Patient Safety Goals ,[object Object]
2012 National Patient Safety Goals ,[object Object]
2012 National Patient Safety Goals ,[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Simultaneously the unit RN had obtained the Vit K on over ride From the Pyxis system( cabinet where medications are kept) and gave the IV dose of Vit K instead of KCL.
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Do Not Use Abbreviations
 
 
How Important is Communication and Patient Safety? ,[object Object]
Behaviors That Impede Patient Safety ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Behaviors That Support A Culture of Safety ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Reporting Incidents: SBAR ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
2012 National Patient Safety Goals ,[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Near Miss ,[object Object]
2012 National Patient Safety Goals ,[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
What Happened ? ,[object Object]
What Happened ? ,[object Object],[object Object],[object Object],Blunt End Sharp End
Additional Medication Safety Issues ,[object Object],[object Object]
TYPES OF ERRORS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
How Often Do Medication Errors Really Occur ? ,[object Object],[object Object]
Medication Errors ,[object Object],[object Object]
Where in the Process do Medication Errors Occur? Reference: http://www.ahrq.gov
Where in the Process do Medication Errors Occur? ,[object Object],[object Object],[object Object],[object Object]
Patient is the Last Line of Defense ,[object Object],[object Object],[object Object]
Do All Medication Errors Result in Harm to Patient? ,[object Object],[object Object]
Key Points ,[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
What Happened? ,[object Object],[object Object],[object Object],[object Object]
Medication Errors : Prevention Strategies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Medication Errors: Prevention Strategies ,[object Object],[object Object],[object Object],[object Object],[object Object]
Medication Errors : Prevention Strategies ,[object Object],[object Object],[object Object],[object Object],[object Object]
Medication Errors : Prevention Strategies ,[object Object],[object Object],[object Object]
Medication Errors: Prevention Strategies ,[object Object],[object Object],[object Object]
2012 Patient Safety Goals ,[object Object],[object Object],[object Object]
Case Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Recommendations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Unintended Medication Discrepancies at the Time of Hospital Admission 6% Severe harm potential 61% No harm potential 33% Moderate harm potential More than half of patient have  1 unintended medication discrepancy at hospital admission Reference: http://www.ahrq.gov
Unintended Medication Discrepancies at the Time of Hospital Admission ,[object Object],Reference: http://www.ahrq.gov
2012 National Patient Safety Goals ,[object Object]

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Revisedpart iipme lecture 2012presentationpart2

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  • 10. Do Not Use Abbreviations
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  • 30. Where in the Process do Medication Errors Occur? Reference: http://www.ahrq.gov
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  • 45. Unintended Medication Discrepancies at the Time of Hospital Admission 6% Severe harm potential 61% No harm potential 33% Moderate harm potential More than half of patient have  1 unintended medication discrepancy at hospital admission Reference: http://www.ahrq.gov
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Notes de l'éditeur

  1. Communication with family/patient is essential. High risk medications include:TPA, Amphotericin,Neuromuscular blockers, Chemotherapy, sedation, analgesia, anesthetic agents, insulin ,Phenytoin, potassium, TPN,Lipids, & investigational drugs. Refer to specific policy if needed
  2. .