Medical errors and whistleblowing
Wednesday, September 22, 2021 14:40
• Goals: medical errors and whistleblowing
○ Identify activities and actions that contribute to medical errors
○ Identify ways to avoid and alleviate medical errors
○ Identify factors that influence thee actions of a “whistleblower”
○ Discuss changes in the way issues and concerns are handled in
healthcare organizations
Medical errors
○ Hinder the safety of patients
• Definition of medical errors
○ “the institute of medicine defines medical errors as a failure of a
planned action to be completed as intended or the use of a
wrong plan to achieve an aim”
§ Causes of injury or even cause of death to the pt
§ D/t medical, transfusion, or surgical errors, falls,
equipment safety, or lack of improper pt monitoring
○ Medical error can also be defined as the harm done to a patient
due to inappropriate personnel in attendance who lack the
appropriate skills to provide the correct standard of care,
perform the appropriate procedures, or decide to not treat the
patient at all
• Medical errors
○ Third largest cause of death following heart disease and cancer
○ Medication errors - largest number of medical errors
§ An event that is preventable involving the inappropriate
administration of a medication or one that causes harm o
the patient while the medication is in the control of the
HCP, pt, or consumer
○ Adverse events
§ A change in which is adversely effected by a treatment or
medication
• Causes of medication error
○ On general care unit:
, § Nursing shortage
§ Sleep deprivation due to shift work
§ Psychological state
§ Longer hours and work weeks
○ In emergency departments
§ High workloads
§ Large volumes of medications time sensitive
• Handoff communication
○ Leading cause of sentinel events
○ Handoff communication allows for:
§ Transfer of information
§ Handoff of responsibilities
§ Opportunities to ask questions
§ Clarity of pt status
○ Inadequate handoff results in:
§ Gaps in information
§ Incomplete knowledge of pt status
§ Errors and patient harm
• Quality of care and patient safety
○ Reporting agencies
§ Institute of medicine (IOM)
§ The joint commission
§ Centers for medicine and Medicaid services
• Oversight organizations
○ The institute of medicine
§ “to err is human”
§ Provision of updates regarding medical errors
○ The joint commission
§ National patient safety goals
§ Sentinel events data base
○ Centers for Medicare and Medicaid services
§ Quality standards
§ Quality based purchasing
• Creation of a culture of safety
○ Recognition that medical errors do occur
§ Mandate the reporting of all medical errors by all
personnel
○ Ethical responsibilities to report
Wednesday, September 22, 2021 14:40
• Goals: medical errors and whistleblowing
○ Identify activities and actions that contribute to medical errors
○ Identify ways to avoid and alleviate medical errors
○ Identify factors that influence thee actions of a “whistleblower”
○ Discuss changes in the way issues and concerns are handled in
healthcare organizations
Medical errors
○ Hinder the safety of patients
• Definition of medical errors
○ “the institute of medicine defines medical errors as a failure of a
planned action to be completed as intended or the use of a
wrong plan to achieve an aim”
§ Causes of injury or even cause of death to the pt
§ D/t medical, transfusion, or surgical errors, falls,
equipment safety, or lack of improper pt monitoring
○ Medical error can also be defined as the harm done to a patient
due to inappropriate personnel in attendance who lack the
appropriate skills to provide the correct standard of care,
perform the appropriate procedures, or decide to not treat the
patient at all
• Medical errors
○ Third largest cause of death following heart disease and cancer
○ Medication errors - largest number of medical errors
§ An event that is preventable involving the inappropriate
administration of a medication or one that causes harm o
the patient while the medication is in the control of the
HCP, pt, or consumer
○ Adverse events
§ A change in which is adversely effected by a treatment or
medication
• Causes of medication error
○ On general care unit:
, § Nursing shortage
§ Sleep deprivation due to shift work
§ Psychological state
§ Longer hours and work weeks
○ In emergency departments
§ High workloads
§ Large volumes of medications time sensitive
• Handoff communication
○ Leading cause of sentinel events
○ Handoff communication allows for:
§ Transfer of information
§ Handoff of responsibilities
§ Opportunities to ask questions
§ Clarity of pt status
○ Inadequate handoff results in:
§ Gaps in information
§ Incomplete knowledge of pt status
§ Errors and patient harm
• Quality of care and patient safety
○ Reporting agencies
§ Institute of medicine (IOM)
§ The joint commission
§ Centers for medicine and Medicaid services
• Oversight organizations
○ The institute of medicine
§ “to err is human”
§ Provision of updates regarding medical errors
○ The joint commission
§ National patient safety goals
§ Sentinel events data base
○ Centers for Medicare and Medicaid services
§ Quality standards
§ Quality based purchasing
• Creation of a culture of safety
○ Recognition that medical errors do occur
§ Mandate the reporting of all medical errors by all
personnel
○ Ethical responsibilities to report
