42010 pablo garcia was given the prednisone ordered

•
4/20/10: Pablo Garcia was
given the prednisone ordered
for Maria Garcia. The
medication dose did not result
in any change in symptoms for
Pablo Garcia.

Medical Error
•
4/30/10. Blaine Presuss was given a
Demerol Shot for pain that was
intended for Joshua Jenquin. Preuss
was heavily sedated and minimally
responsive for several hours
•
5/10/10: Maximum dose of heparin
was given 3 times in one day. The
order was written to titrate the
dose based on patient lab levels.
•
5/12/10: Blood was ordered for
Alaine Johnson, but
administered to Yasmin Johnson.

The Response To The Medical Error To
Reduce Liability
•
HIPAA Breach Notification Rule
–
Notification to the following within 60 days of breach:
•
Individuals affected
•
Media
•
Department of Health and Human Services
•
Address the causes of the Breach by conducting
an assessment
•
Determine steps to ensure this type of breach
never occurs again

Joint Commission Concerns
•
National Patient Safety Goals
–
Set of Standards To Help Prevent Medical Errors
•
Miscommunication Between Caregivers
•
Not Using Equipment Properly
•
Medication Errors

Quality Improvement Strategy To Reduce
Medical Error
•
Medication Errors
•
Amend Policy’s and Procedures to ensure Double verification of Medication
in pharmacy.
•
Barcode scanning process for medications to ensure the correct patient is
receiving the correct dose.
•
Require provider verification before Medication is disburse from pharmacy.
•
Pharmacy review for appropriateness of ordered medications.

Quality Improvement Strategy To Reduce
Medical Error Cont.