Module 6 Critial Thinking.docx - Running Head: HEALTHCARE...

Running Head: HEALTHCARE ERROR ASSESSMENT REPORT 1
Option #2: Healthcare Error Assessment Report
Andrea Lane Whittaker
Spring 18-D-8
HCM-520 Quality and Performance Improvement in Healthcare
Colorado State University – Global Campus
Dr. Kimberly M. Ondo, PHD
July 22, 2018

HEALTHCARE ERROR ASSESSMENT REPORT
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Introduction
Error prevention needs to be an important part of Quality Management in promoting a
culture of safety as medical errors continue to occur. To address this problem, there must be a
change to a medical culture that provides a nonpunitive response of individuals to allow open
discussion about errors. Accountability is still required, however. This plan should include
feedback and communication by all stakeholders, including clinician, risk management, change
management, C-Suite management and the board to move in the direction of evidence-based,
quality patient care and minimize medical errors. An investigation should take place and include
data collection, aggregation and analysis of processes, identifying the error, and reporting it,
allowing the organization to be better informed to improve patient safety and minimizing risk.
A case involving a medical error occurred when a 76-year-old patient suffered a fall
causing a right humeral fracture which was managed conservatively. Following correction of the
fracture, an upper extremity blood clot caused from Heparin induced thrombocytopenia.
Immediate anticoagulation was necessary. Lepirudin was started at 9:13 p.m. at an initial dose of
7.2 mg/hr. Over the next two days the dose was changed by the doctor. At 6:00 a.m. on day three,
the Lepirudin was running at a rate of 0.5 mg/hr. At 3:25 p.m. per doctor’s orders the nurse
adjusted it to run at a maximum dose of 16.5 mg/hr. overnight and then it was to be readjusted in
the am. The nurse reported knowing the dosing ordered by the physician entering the information
into the IV pump incorrectly causing the high dose to continue through the following day. The
patient developed decreased responsiveness, found to be extremely anemic, received a transfused
and was admitted to the Medical Intensive Care Unit. It was identified that the patient had
received an overdose of Lepirudin which has no reversal agent. She died on day four from
hemorrhage due to an overdose of Lepirudin (Lubin & Meyer, 2011).
To: The Chief Executive and Board of Governors

HEALTHCARE ERROR ASSESSMENT REPORT
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Medication errors are costly to the hospital in law suits and in reputation. They
compromise patients’ safety and are a global problem that causes unintended harm to patients