Safety and Quality in Clinical Practice and Issues in Medication Administration Flashcards
What is a clinical incident?
Any unplanned event that occurs and has or has the potential to result in harm to a patients or others involved.
What Factors contribute to a clinical incident?
Human factors: skill based error, cognitive error and rule violation.
System Factors
What is the difference between skill based errors, cognitive errors and rule violations?
Skill Based Errors: are accidental and results when a nurse forgets a step in a routine task
Cognitive Errors: are accidental, result from errors in thinking or judgement (misinterpretation or lack of information)
Rule Violation: intentional, occurs when nurses knowingly violate a rule
What is a root cause analysis?
An investigation of any clinical incident that is considered high risk
What are key steps in managing clinical incidents appropriately?
1) identify the mistake that caused the incident to occur
2) take appropriate action to reduce harm
3) make a notification to IIMS
What is the role of WHS legislation?
To minimise or prevent accidents and clinical incidents, by reducing the risks to health and safety in the workplace.
What are the nurses responsibilities in WHS?
- Working to their capabilities and training
- Taking action to avoid or minimise the risk of hazards
- Working with WHS policies and procedures
- Reporting incidents to the NUM
What are the requirements for a telephone order of medication?
1) ISBAR: identify the patient, their situation currently, why they are in hospital, what assessments you have done and what medication you believe should be given
2) The medication, dose, route, and frequency must be provided and read back to the prescriber with numbers as separate words
3) Must be repeated by another nurse back to the prescriber
4) GP must send written confirmation order or sign order in 24hrs
What must be recorded on the register for S8 medications?
- Patients name
- The prescribed drug, dose, GP’s name and date & time of administration
- Balance of medication
- Checked and signed by 2 nurses
How are S8’s stored?
Must be kept under a lock and key. A nominated RN has the key and drugs are stored where the public doesnt have access.
What is involved with the destruction of S8’s?
If S8’s are unusable it must be destroyed, recorded and accounted for by 2 nurses in the drug register.
What are causes of medication errors?
Transcribing orders
Insufficient knowledge of medications
Disruptions and interuptions
