Patient Safety Critique

Patient safety critique

Introduction

The Vice President of St. Luke's Quakertown Hospital, Judy Smetzer, was a nurse when she began her career and later she gained different management positions. Her work focuses upon quality improvement and risk management. She published many articles on medication error prevention including “Lessons from Colorado: Beyond blaming individuals”. In this article she has discussed fourteen system failures that were faced in the case of new born Miguel. These 14 system failures were:• Incomplete clinical information• The language barrier• Inconsistent procedure for communicating prenatal care• Staff inexperience and poor documentation• Nonstandard method of writing the drug order• Insufficient drug information• Lack of a unit dose system• Insufficient information on infant injections• Inconsistent independent double check system• No staff education before dispensing non-formulary drugs• Insufficient drug information and inadequate drug references• Unclear definition of non-physician prescriptive authority• Unclear manufacturer labeling• Conflicting information on IV use of milky white substances

The article is related to the event of the death of a new born Miguel. The event took place in 1996, in which three nurses were charged of careless stabbing. Smetzer reviewed the case for the identification of the different failures in the system that helped this error to occur. Our discussion includes the patient safety critique and the two errors resulting in the system failure. These errors include the “incomplete clinical information” and “insufficient drug information and inadequate drug references.” For each system failure, the discussion regarding precautions that needs to be taken for avoiding the system failure; its affiliation with the concerned discipline; and most modern research work done in a particular system failure will be reviewed (Emanuel et al, 2002).

Discussion

Patient safety has always been a serious concern for every individual and government related with the health care department. Patient safety is defined as a study of designing the safe methodology in order to achieve a trustworthy system regarding the health care delivery. It involves the discussion of incidence and events that might help to maximize the recovery of health care system.

Smetzer has discussed fourteen different errors that are a cause to health care system failure. In her article “Lesson from Colorado: Beyond blaming individuals”, she has discussed briefly the errors regarding the system failure. Her article reveals the event from Colorado that took place in 1996 in which three nurses were charged due to reckless homicide (Kennedy et al., 1992). Due to their carelessness death of the new born Miguel occurred. She discussed the case and mentioned the failures that resulted to the death.

Incomplete clinical information and insufficient drug information are the two system failures which are the main part of our discussion. These two errors are of worth importance in order to construct a plan to recover the system failure. Precautions against the two errors help to visualize the advancement of the health care system.

Incomplete clinical information

Instant right to use to offered clinical information is insufficient in existing medical practice. The lack of knowledge and incomplete clinical information causes the medical system ...