Preventable Medical Errors
Discussion Topic
Quality and risk management programs have their foundation in two significant Institute of Medicine (IOM) published reports. Several measures and tools have been developed to provide continuous quality improvement in the healthcare industry. Healthcare administrators are actively involved to ensure the tools and measures are available to evaluate quality healthcare standards. Medical errors continue to occur in healthcare requiring re-evaluation of tools and measurements. Patient safety can be improved by identifying untoward events, learning how they occur, and developing programs to prevent them (Rodziewcz, Houseman, & Hipskind, 2020). The videos provide the foundation of change discussing viable solutions to improve the quality of care.
Falls Management Program Case StudyLinks to an external site.
Mrs. P is a 93-year-old white female admitted to your facility. She has had Alzheimer’s disease for approximately 7 years and has been cared for by her husband and daughter at home. Her other past medical problems include diabetes mellitus, hypertension, osteoarthritis, depression, and a history of falls. Over the past several months, her family has found it increasingly difficult to care for her at home due to worsening symptoms of agitation and insomnia.
Mrs. P has been at your facility for 3 days and has slept only 3 hours per night. She is extremely restless and anxious and often cries out for her husband. She constantly wants to get up from her chair or bed. Mrs. P was found on the floor by staff at 8 pm and apparently had fallen onto her buttocks; no injuries were found. Mrs. P was assisted to bed for the night. A waist restraint was placed on her and all four side rails were positioned in the upright position.
Later that evening Mrs. P was found on the floor. Her undergarments were soiled and she continued to cry out for her husband. She was assessed to have no injuries resulting from the fall. The nurse obtained an order for a sedative from the physician and Ativan 1.0 mg was given at 1 am. She was put back to bed and finally went to sleep for the night. (Agency for Healthcare Research and Quality, 2017)
References:
Agency for Healthcare Research and Quality. (2017). The falls management program: A quality improvement initiative for nursing facilities. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html#inservice1Links to an external site.
Institute of Healthcare Improvement. (2013). Six IOM AIMS for improvement. https://youtu.be/Rj11j2F5BSA
Patel, K. (2019). To err is human. https://youtu.be/MXEAIoeYUno
Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Prevention. 2020 Oct 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29763131. https://pubmed.ncbi.nlm.nih.gov/29763131/


Instructions
Please review the videos discussing the steps taken to improve and eliminate medical errors and improve quality. Medical errors continue to occur within healthcare. There are two types of errors; errors of omission and errors of commission. This week’s discussion involves a scenario and the approach taken to correct the error.
Discuss the current scenario and the actions of the employees, what alternative actions may have been performed.
Discuss the scenario and videos in reference to the scenario to errors of omission and commission. For this incident, is this considered error of omission or commission. Explain why.
What measures may be taken to prevent further incidents?
HCA what steps(policy and procedures) can be implemented to ensure patient safety and quality of care?