Using a SYSTEMS APPROACH to address patient safety a case of MEDICATION ERROR.
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1 Using a SYSTEMS APPROACH to address patient safety a case of MEDICATION ERROR. By: George Kumi Kyeremeh. Director Nursing & Midwifery. Ghana. Presenter: Josephine Kyei BA NURSING,MPHIL HEALTH SER ADM FWACN
2 Outline Introduction The Case Investigations Lessons Quality interventions
3 Food for thought Lawyer and a Health Professional- What is the difference? A lawyer only robs you of your money but a health professional robs and kills you
4 Introduction What is a system? System has interrelated parts that function in a well coordinated fashion to achieve a common goal.
5 Components of a system Components of system -Inputs -Processes -Outputs -Outcomes -Impact
6 Systems approach to Quality Issues All the actions that take place at the different parts of the system (input...outcome) are taken into consideration... Mistakes normally occur at the processes stage.
7 Systems approach to Quality Issues BLAME game normally hides the under lying causes. Preventing the opportunity to alter the system to avoid future occurrence.
8 Introduction of case A case report of Eastern Regional. Their experience on look alike packaging. Information was initially received with shock, anger, disappointment and blame. However, a systems approach to problem-solving led to realistic quality interventions that produced measurable results.
9 CASE SETTING
10 The case- Initial information At a Workshop. Announcer- A very bad case! A nurse has killed a mother by giving IV MgSO4 instead of Metronidazole. General Response. What!! OOHH My God.. Unpardonable mistake. Nurse must be severely punished. What is that? What what
11 An insightful opinion A participant at workshop: The staff though is responsible for her action, Let s take a critical look at all the contributory factors. Let s look beyond blaming an individual and focus on the system. Use the systems approach instead of personal attack.
12 Quick enquiry Enquiry at pharmacy revealed that: 1. IV Metronidazole and IM MgSO4 used to be packaged differently. (Former- Ampoule and Latter-infusion type) 2. Manufacturer later re-packaged Metronidazole from amp. to infusion type 3. Two (2) products now look alike. Very confusing???
13 The Story of Magnesium Sulphate. 9/21/
14 Field visit Facility interview revealed: 1. Every inpatient was given a medicine pack. 2. Three (3) 500mg Metronidazole infusions prescribed. 3. One (1) happened to be MgSO4. 4. Faulty pack sent to Ward. 5. First 2 correctly administered by Midwife. 6. Wrong one (last) administered by Junior MidWife.
15 Situational reality. 1. Midwife attended a new labor case 2. A junior Midwife asked to administer last dose of metronidazole. 3. Quickly obliged and performed duty. 4. The patients condition suddenly changed 5. There was suspicion of drug reaction. 6. Empty bag of MgSO4 was then discovered. 7. Patient later died-sadly.
16 Reflections Could this death have been avoided? How? Who should be held responsible? Why or Why Not How do we guard against its future occurrence?
17 Reaction at facility Administration/Pharmacy Staff in shock;why such blunder? Disturbed and suspected foul play Considered seeking transfer Great confusion and suspicion Looking for cause of the mishap
18 Ward Sorrow, guilt and grief Staff psychologically disturbed Difficult to exonerate oneself Why, why why.
19 Response Regional level Immediate phone calls followed by Circulars Investigation team constituted Regional Clinical Care Unit coordinated activities Other cases uncovered. Recommendations made to Manufacturer
20 What was put in place Facility level MgSO4 marked red and stored separately Cross-checking (pharm. ward) Double check before giving medicine Seek second opinion if unsure Orientation-new unfamiliar medicine Adherence to protocol. Manufacturer changed packaging
21 Re-packaging
22 Conclusion 1. Individual responsibility is important but not enough. 2. Hardly will a problem be associated with an action of an individual alone. 3. Many errors occur at Process Phase 4. Systems approach to problemsolving facilitate long-lasting solutions 5. Blame game usually hides vital information. 6. Tackle issues and not personality.
23 Food for thought Remember that someone s life is in our hands today. Tomorrow it may be yours. You health staff will have more souls to answer before God than we the Army Generals Napoleon
24 End of Presentation Dedicated to all victims of medical errors. Thanks for listening
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