Assignment task: Patient Safety Essay
Part I: Introduction:
Patient safety continues to be a significant issue in healthcare, with medical errors among the leading causes of preventable patient harm worldwide. Errors such as medication mistakes, misdiagnoses, and surgical complications can result in major morbidity, mortality, and emotional suffering for both patients and healthcare professionals. The documentary Chasing Zero: Winning the War on Healthcare Harm underscores the importance of fostering a culture of safety in healthcare systems, emphasizing the critical need to address these preventable mistakes (Texas Medical Institute of Technology, 2010). The title of the documentary encapsulates the aspirational goal of zero medical harm, a standard that necessitates ongoing vigilance, systemic changes, and accountability in the medical field.
One significant error highlighted in the film is a medication administration mistake where a patient was given an overdose due to inadequate communication and lack of verification processes. This error stemmed from a failure in the communication chain and oversight in double-checking medication dosages, reflecting deeper systemic issues that compromise patient safety. Want Online Tutoring?
Part II: I need more details, per my crazy English Professor
Clinical Judgment Model (CJM)
The Clinical Judgment Model (CJM) provides a structured approach to clinical decision-making. It comprises five steps: getting the information, making meaning of the information, determining actions to take, taking action, and evaluating outcomes and your thinking. Each of these steps can help analyze the medication error highlighted in Chasing Zero.
1. Getting the Information
In the context of the medication error, the first step involves collecting all relevant data, such as patient history, medication dosages, and the protocols in place for administering medication. The failure to obtain complete information, especially regarding the patient's allergies or previous medication reactions, can lead to critical errors. According to the CJM, a fundamental competency here is "safety," which emphasizes the importance of creating an environment where accurate information is consistently communicated and verified among healthcare providers.
2. Making Meaning of the Information
Once the information is gathered, the next step is interpreting it effectively. In this case, the healthcare team may have misinterpreted the medication order or the patient's current status, leading to the overdose. A key competency in this step is "teamwork and collaboration." Encouraging open dialogue among team members can help ensure that everyone has a clear understanding of the patient's needs, thus reducing the risk of errors.
3. Determining Actions to Take
After accurately interpreting the information, the team must determine appropriate actions. Here, the healthcare providers failed to implement the necessary double-checking processes before administering medication. The relevant CJM competency at this stage is "evidence-based practice." Adhering to established guidelines and protocols for medication administration can help ensure patient safety by minimizing the risk of errors.
4. Taking Action
The actual administration of medication is where the error occurred. It is crucial for healthcare professionals to follow the prescribed protocols diligently. In this instance, the absence of a verification system meant that the overdose went unnoticed until it was too late. The "quality improvement" competency is vital here, as ongoing assessments and adjustments to practices can significantly enhance safety protocols.
5. Evaluating Outcomes and Your Thinking
Finally, evaluating the outcomes involves reflecting on what happened after the medication error. The aftermath of such incidents often includes not only the physical effects on the patient but also emotional repercussions for healthcare providers. The "informatics" competency applies here, as utilizing data to analyze errors can facilitate better learning and prevent similar occurrences in the future.
Through this application of the CJM, I can see how systematic errors in each step contribute to patient harm, reinforcing the need for a more robust safety culture in healthcare settings.
Clinical Judgment Model (CJM)
Discuss each step of the Clinical Judgment Model:
- Getting the information
- Making meaning of the information
- Determining actions to take
- Taking action
- Evaluating outcomes and your thinking
- Incorporate one CJM competency in your discussion of each step
- Clearly describe how you used the CJM to identify the error discussed in your introduction.