-Central line-associated bloodstream infections (CLABSIs) area type of harm that providers once thought to be an inevitable side effect of care, but they now consider to be preventable. Can you think of any other examples of harm in health care that is now considered preventable? catheter-associated bloodstream infections -Do you agree with Dr. Bates that the definition of harm from the Harvard Medical Practice Study is too narrow? Why would it be advantageous to take a broader view of harm? -Complete PS 102: From Error to Harm Module (2 hours) and save certificate. -Discuss attached case study: “An Insulin Overdose” -In this case, insulin was routinely distributed from the OR pharmacy in high concentrations, thereby posing a great danger if administered incorrectly. Can you think of an example in your own work environment where you thought to yourself, “This is a disaster waiting to happen!” – Now that you have identified examples from your work environment, take a closer look at the suboptimal systems that may be at work. Why does this “disaster waiting to happen” exist in your workplace? Is it because there is no reporting system for such situations? Do the employees feel disempowered to change their workplace? There are many possibilities. -Next, what are some ways in which those systems could be improved? d. Let us assume that the resident caught her mistake before she injected the syringe with insulin, so that no harm was done. We may think of such a scenario as a “near miss” event. In many work environments “near misses” are greatly underreported, and the opportunity to learn from them gets lost. If you are a clinician, can you think of a “near miss” experience of your own? How did you change your practice as a result? – Mistakes and adverse events often trigger the “who” rather than the “how” question, thereby fostering a blaming environment in which reporting mistakes and near misses does not feel safe. Think of a mistake or near miss that you observed at work. How was it handled? Did the organization’s response to the error make you more or less likely to report your own mistakes? -Complete PS 103: Human Factors and Safety Module (1hr) and save certificate.8. Take a few moments to listen to Rani, as she tells us about the lasting effects of her experience, including how she feels seven years later. https://youtu.be/IASldY_0tfA a. How does hearing from the patient affect your feelings about this story? b. How can we prevent Rani’s experience from happening with another patient? -Journal: Write a reflection of what you learned completing these assignments and how it applies to your role as a student nurse and your future role as an RN. Make “3 promises/strategies” that you will incorporate into your practice to reduce harm to clients. (No more than 1 page) Health Science Science Nursing NUR 211 Share QuestionEmailCopy link Comments (0)
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