It is the most feared mistake of a nurse: a medication error resulting in the death of a patient. The article, "Lesson from Colorado: Beyond Blaming Individuals” by Judy Smetzer identifies fourteen system failures which led to the death of an infant. By explaining each of the fourteen failures, Smetzer explains how such a grave mistake is not the fault of a single person or a single component of a system, but the fault of the systems collectively. Two of the system failures identified, incomplete clinical information and conflicting information on intravenous use of milky white substances, contributed significantly to the error. Several precautions need to be instituted to avoid a repetition of these system failures in the future.
First and …show more content…
The neonatologist stereo-typed the parents and felt they would not understand the importance of follow up care. Hospital administration needs to institute policies for proper identification of cultural differences, and the nurses would then need to implement these policies. Current research regarding language barriers and medical error indicates medical errors are higher among non-English speaking patients. Data shows those who are not proficient in English have nearly twice the incidence of adverse events involving physical harm. (Divi, 2007).. In the article, “When language intervenes,” Olivia suggests that language proficiency be determined as soon as a patient arrives at a facility. In doing so, the need for a translator would be determined beforehand, allowing for clear communication between patients and hospital staff (Olivia, 2008). This is important because hospitals are responsible for the well-being of all in their care, and it is inevitable that there will be times that a patient does not speak English. The only way the hospital can ensure the best possible care for each patient is to ensure that problems are accurately communicated. If language proficiency was immediately determined, there would be less risk of miscommunication, and consequently less mistakes resulting from …show more content…
Additionally, mixing of IV medications can result in formation of precipitate which can cause adverse outcomes. Several IV medications are milky white in color, such as Lipids and the IV sedating drug Propofol. Occasionally, color changes could be a normal and expected outcome of administration, but a pharmacist should be contacted if a color change or haziness is noted. Visible labeling should be indicated on the medication by the pharmacy department indicating that color of the medication to prevent additional errors and increase communication. Furthermore, a nurse administering intravenous therapy needs a proper understanding of which medications can be safely administered intravenously. The responsibilities of the nurse administrating the infusion therapy includes screening the patient prior to administration and monitoring the patient before, during and after the administration (Fulcher,
First and …show more content…
The neonatologist stereo-typed the parents and felt they would not understand the importance of follow up care. Hospital administration needs to institute policies for proper identification of cultural differences, and the nurses would then need to implement these policies. Current research regarding language barriers and medical error indicates medical errors are higher among non-English speaking patients. Data shows those who are not proficient in English have nearly twice the incidence of adverse events involving physical harm. (Divi, 2007).. In the article, “When language intervenes,” Olivia suggests that language proficiency be determined as soon as a patient arrives at a facility. In doing so, the need for a translator would be determined beforehand, allowing for clear communication between patients and hospital staff (Olivia, 2008). This is important because hospitals are responsible for the well-being of all in their care, and it is inevitable that there will be times that a patient does not speak English. The only way the hospital can ensure the best possible care for each patient is to ensure that problems are accurately communicated. If language proficiency was immediately determined, there would be less risk of miscommunication, and consequently less mistakes resulting from …show more content…
Additionally, mixing of IV medications can result in formation of precipitate which can cause adverse outcomes. Several IV medications are milky white in color, such as Lipids and the IV sedating drug Propofol. Occasionally, color changes could be a normal and expected outcome of administration, but a pharmacist should be contacted if a color change or haziness is noted. Visible labeling should be indicated on the medication by the pharmacy department indicating that color of the medication to prevent additional errors and increase communication. Furthermore, a nurse administering intravenous therapy needs a proper understanding of which medications can be safely administered intravenously. The responsibilities of the nurse administrating the infusion therapy includes screening the patient prior to administration and monitoring the patient before, during and after the administration (Fulcher,