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Please response to each statement or question with 100-250 words. 

 

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Research shows that if the first three leaps (Computerized Physician Order Entry, Intensive Care Unit Physician Staffing and Evidence-Based Hospital Referral) were implemented in all urban hospitals in the U.S. we could save over 57,000 lives, prevent as many as 3 million serious medication errors, and save $12.0 billion each year (Lwin 2008).(The LeapFrog Group, 2014) Preventive care is the key to population health.  The factor that will drive health care costs down is avoiding chronic disease.  Many insurance plans are now rewarding their members for healthy behaviors.  Leapfrogs annual hospital reports that evaluate the care a hospital provides and are based on quality of care, were controversial because the hospitals that topped the list were not the traditionally well known hospitals, but  hospitals that actually had the least medical errors. Value based contracts, contracts that pay physicians based on the quality of care they provide, are now mandated by many states, including South Carolina.  

 

 

In order to fully understand what defines a medical error, you have to understand what defines patient safety.  The National Patient Safety Foundation defines patient safety as the prevention, avoidance, and amelioration of injuries or adverse outcomes stemming from the process of health care delivery while the Institute of Medicine defines patient safety as freedom from accidental injury. From this understanding of patient safety, we can understand that a medical error is many things; the use of a wrong plan to achieve an aimthe failure of a planned action to be completed as intended, an unintended act, an act that does not achieve its intended outcome, or deviations from the process of care, regardless of if it causes patient.  I have been a nurse for six years. I see medical errors happen literally every day. Some errors are small, some are HUGE and insanely scary. Antibiotics that are overdue on a patient or are delayed by pharmacy. Falls. Faulty equipment. Orders on the wrong patient. Wrong insulin doses. Errors in communication. Discharged patients with IVs still in. Failure to make patients NPO who cant safely swallow. Self-extubation. Some scary stories: air embolism after central line removal in a patient sitting upright on the side of the bed. Hyper extension of the neck that cause quadriplegia and vent dependency. 

 

 

Medical malpractice cases arise when a patient is harmed by a doctor or nurse (or other medical professional) who fails to provide proper health care treatment. (“Nolo Law For All”, 2014)When I worked in the operating room one of the physicians left a ribbon retractor in a patient.  It seems like doing this would be nearly impossible since a ribbon retractor is about 12 inches long and 2 inches wide.  But when you are on the in a hectic situation it’s easy to have things get out of hand.  This was back in the early 90’s, before counting instruments was the norm for all abdominal surgeries.  Needless to say after this happened, the policy changed shortly afterwards.  Having this happen was probably instrumental in the change in policy for the hospital.

 

 

 

 

Why do concepts related to the Just Culture concept apply to this week’s materials?

 

 

http://www.health.ny.gov/professionals/patients/patient_safety/conference/2007/docs/patient_safe

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