Concept Analysis : Interruptions And Medical Error

This reading discusses the use of wireless alerts pagers in a Surgical Intensive Care Unit and how it affects both work practices and information flows through a qualitative study. From the research that exists, we can see that pagers are successful communication tools because of the mobility and immediacy they provide. Interviews were completed with physicians and pharmacist who used the pagers and nurses who did not use the pager about how it impacted their work. In addition to collecting data this way, the researchers also compiled observational data from watching the device be used in regular practice. The study noted that

Data input is critical in the medical office environment – it is essential that all information that is input into the system or other documents are up-to-date and accurate. Multitasking is a required skill for being a medical assistant, but with constant distractions such as patients, ringing phones, and coworkers, it can be easy to slip up and enter the wrong information, which is why consistently double and triple checking to ensure correctness is vital. Misinformation may result in documents and records being misfiled, which can lead to missed appointments, incorrect patient files, and frustration from both clients and physicians. Business interactions such as billing, receipts, consent forms, and other documents rely on precise information

Gill P.S., Kamath A., & Gill T.S. (2012). Distraction: an assessment of smartphone usage in health care work settings. Risk Manage Healthcare Policy 5(9), 105–114. doi: 10.2147/RMHP.S34813

Unintentional errors, near-misses, and adverse patient outcomes occurring in the intensive care unit can range from significant to fatal. These errors have

    The modern day emergency room is a department that is constantly busy. In the hustle of caring for patients, there are some details of the patient’s care that can be overlooked in a standard phone report to the accepting nurse. With this in mind, a change is needed so that there is an optimum patient outcome for each and every one of the people that walk through the doors of the emergency room and get admitted.

Nurses on the Progressive Care Unit (PCU) experience many interruptions during patient care, including medication administration. These interruptions can affect proper and safe medication passage. The time taken to manage interruptions can be diverted back to the patients to assist in safe medication administration.

According to Pennsylvania Patient Safety Reporting System (PA-PSRS), nurses stated fatigue as a contributing factor to errors related to procedures, treatments, tests, and medication administrations (Gardner, Dubeck, 2016). Many "near" errors, or “close-calls” were also attributed to mental fatigue and lack of recovery time between shifts (Maust Martin, 2015). It is reported that errors and "near" errors are related to factors, such as, lapses in attention, reduced motivation, compromised problem solving, and diminished reaction time. The Joint Commission believes that fatigue is a factor that greatly contributes to the increased number of sentinel events among patients (Gardner, Dubeck, 2016).

According to the Institute of Medicine (IOM) report, To Err Is Human, the majority of medical errors result from faulty systems and processes, not individuals (Hughes, 2008). However, due to processes that are inefficient and variable, multiple health insurance, differences in provider education and experience, and other factors that contribute to the complexity of health care the IOM has put together six aims of health care that is effective, safe, patient-centered, timely, efficient, and equitable (Hughes, 2008).

In healthcare today, when hospitals are judged upon patient safety standards, it is critical to prevent errors involving medication administration. Distractions while preparing and administering medications, has been report as one of the leading causes of medication errors. Distractions while nurses are administering medications can lead to poor patient outcomes and even sentinel events. Nurses and nurse managers are responsible for maintaining a unit with minimal distractions. When distractions are minimized throughout medication administration process, a decrease in medication errors will occur and lead to increased patient outcomes.

Medication errors are one of the leading causes within a patient care setting thatcan jeopardize the client’s safety, and can even potentially be fatal. The six patient rights,right dose, time, route, medication, patient and documentation, all help prevent errors andpromote patient safety. The nurse needs to check off each patient right in order tosuccessfully pass medications. One of the leading causes for missing one of these patientrights is interruptions in the process of medication administration prep, or when activelygiving the medication to the patient. This paper will discuss why interruptions duringmedication administration can cause errors, and interventions the nurse can do to avoidputting the patient in

The concept is a general idea that is derived from human perception of events in the environment. This is based on the belief that occurrences in a given context are necessary to a wholesome interpretation of a phenomenon ( McEwen, Willis, 2011, pg,.25).Applications of concept analysis to clinical practice has become accepted among practitioners as paradigms of practice.

According to Barry (2014), the Joint Commission has acknowledged the severity of complications associated with communication mistakes, for as much as 70% of adverse medical events, 75% of which lead to patient death, are a result of communication breakdowns. Barry (2014) also states that instances of miscommunication cause over two-thirds of adverse effects among patients. As noted by Malekzadeh, Mazluom, Etezadi, and Alireza (2013), as much as 69% of medical errors are preventable in nature and the fact that these issues still plague the field of healthcare in the 21st century is quite perplexing. Therefore, it is the goal of this charter to identify means and ways in which hand-off discrepancies may be minimized and further eliminated, by implementing a tool that will drastically decrease the percentage of handoff errors resulting from a breakdown of communication.

Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)

In observation, (Fahnestock, McComb, & Deshmukh, 2013) stated "Information technologies are transforming the way healthcare is delivered. Innovations such as computer-based patient records, hospital information systems, computer-based decision support tools, community health information networks and new ways of distributing health information.” (p.3.2). In the sector of delivering healthcare using technology, has made it easier for healthcare professionals to access medical records, digitization of prescriptions and view test results. With the use of high-performance devices being used in the hospital, helps to make the jobs of healthcare professionals a little easier. As well as relieve anxiety from anxious patients that may be awaiting lab results to come back. Therefore, IT devices and services has been and continues to be a tremendous help and game changer for the healthcare system. However, there is still a lot of work to be done to help shape and reform the healthcare

The goal of this literature review is to increase our knowledge about technology use in practice and to identify where there is need for improvement. Information technology seems to be a widely discussed topic these days and most nurses have no clear idea how it can transform the way we do things on an every day basis. We will also look at the impact technology has on nursing, patients, and colleagues. We will then focus on a specific nursing setting, in this case the emergency room. This literature review is organized to grow on each independent section so that you, the reader, can form your own opinion, but take with you the universal understanding of how information technology will lead us down a new and exciting career path.