Learning from near misses in an effort to promote patient safety.
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Biomedical subjects
Publications and source records attributed to Suzanne C Beyea.
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Although medication errors can result in serious patient complications or even death, a paucity of information regarding medication errors that occur in the OR exists. AORN and the US Pharmacopeia (USP) collaboratively conducted a secondary analysis of reports of medication errors that occurred in the OR. These reports were submitted to the USP via the Medmarx program. The findings will give perioperative clinicians further insight into the types and causes of medication errors that occur in the OR and will help them develop potential prevention strategies.
Registered nurses in perioperative settings and managers of perioperative departments must work together to implement policies and procedures to ensure compliance with these very important federal regulations. If the information is not recorded in the proper manner and shared with the manufacturer, patients' safety is at risk. Without the ability to contact physicians and patients, manufacturers cannot alert individuals appropriately if problems arise with a certain device. Tracking devices in the correct manner ensures that patients can be notified expediently. Nurses and managers should examine their current practices to ensure that they are consistent with federal regulations. A regular assessment should be conducted to ensure that tracking forms are completed in an accurate, timely manner, that permission to release a patient's social security number is obtained, and that the hospital is compliant with the FDA's most up-to-date list of devices that must be tracked. All perioperative staff members must receive education about the tracking process in their particular institution and receive updates when the process or FDA regulations change. Maintain patient safety by ensuring that the medical device tracking process is followed accurately and meets federal regulations.
A culture of safety is an achievable objective for perioperative management. Research in analysis, safety factors, alarms, instruction, and management can make this change rapidly. It is important to build the data and evidence for those practices that show improved patient outcomes. Those practices and the processes that develop them should be sanctioned by responsible organizations in active collaboration.
Because health care delivery increasingly requires timely information for effective decision making, information technology must be integrated into nursing education curricula for all future nurse clinicians and educators. This article reports findings from an online survey of deans and directors of 266 baccalaureate and higher nursing programs in the United States. Approximately half of the programs reported requiring word processing and e-mail skill competency for students entering nursing undergraduate programs. Less than one third of the programs addressed the use of standardized languages or terminologies in nursing and telehealth applications of nursing. One third of the programs cited inclusion of evidence-based practice as part of graduate curricula. Program faculty, who were rated at the "novice" or "advanced beginner" level for teaching information technology content and using information technology tools, are teaching information literacy skills. The southeastern central and Pacific regions of the United States projected the greatest future need for information technology-prepared nurses. Implications for nurse educators and program directors are discussed.
The Association of periOperative Registered Nurses (AORN) has committed organization resources to address the worsening shortage of qualified professional registered nurses in the operating room. Organizationally, the efforts have addressed assisting members to recruit new staff and provide orientation and educational experiences that prepare competent practitioners for this specialty. As well, the organization has developed educational programs, membership programs, and other services to support AORN members to develop mentoring relationships with students and new staff. Other organizational efforts include legislative activities and collaborative relationships with other organizations.
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AORN is committed to promoting the identification of the correct surgical site. Using the suggested risk-prevention strategies when developing policies and procedures will reduce the risk of error. AORN's position statement on correct site surgery is available on AORN Online (i.e., http://www.aorn.org/about/positions/correct site.htm). Other resources can be found on the Patient Safety First web site (i.e., http://www.patient safetyfirst.org). As patient advocates, perioperative RNs should communicate with all members of the surgical team to verify the correct surgical site. Individual facility policy should clearly delineate the role and responsibility of the physician and other team members in marking and verifying the patient's-identity and the correct surgical site, procedure, and laterality. Perioperative nurses also should think about the last time an error or a near miss related to wrong site surgery occurred. Compare your facility's current policy and procedure to JCAHO recommendations and work within your facility to develop, implement, and monitor a collaboratively developed, multidisciplinary policy and procedure. If your facility has not addressed the issue of wrong site surgery, learn more about why this problem occurs and see what you can do to make correct site surgery an expectation--100% of the time.
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