b'| LEADERSHIP GUIDEstep along the pathway that begins when areferred to as near misses. of the events that led up to the adverse clinician prescribes a medication and endsCulture of safety: An environmentevent can be documented and areas for when the patient actually receives the med- established due to an organizationalimprovement to prevent the event from ication (PSNet, 2018). Commission referscommitment to safety that permeatesrecurring can be identified.to an action that is taken. For example, aall levels of the organization. Some char- Sentinel event: A term coined by the nurse administers the wrong medication toacteristics of a culture of safety includeJoint Commission to define an adverse a patient. This is an act of commission. Anacknowledgment of the high-risk, error- event in which death or serious harm act of omission occurs when an appropriateprone nature of the organizations activ- occurred.action is NOT taken. For example, a nurseities; an environment where employees forgets to give a patient his medication. Thiscan report errors and near misses with- IMPACT OF THE INSTITUTE OF MEDICINES is an act of omission. out fear of reprimand or retaliation; and(NATIONAL ACADEMY OF MEDICINE) An adverse drug event (ADE) is harmcollaboration among all levels of employ- RESEARCH ON PATIENT SAFETYexperienced by a patient as a result of expo- ees to seek solutions to problems andJanuary 2000: The chief nurse executive of sure to a medication (PSNet, 2018). It isenhance safety. a large metropolitan hospital met with her important to note that the occurrence ofHigh-alert medications: Medicationsmanagement staff to discuss the Institute of an adverse drug event does not necessarilythat have an increased risk of caus- Medicines (IOM) report To Err is Human mean an error has occurred (PSNet, 2018). ing patient injury when misused.and the changes that must be made to the There are several types of ADEs, includ- Consequences of errors involving high- delivery of nursing care as a result of the ing (PSNet, 2018): alert medications may be more seriousinformation provided in the report. The IOM Preventable adverse drug events: Thesethan with other drugs. report has shaken the healthcare community events occur as the result of a medicationJust culture: An organizational cultureand the general public as well. Hospitals are error that causes any degree of harm.in which employees are comfortablealways striving to be safer!Research shows that about 50% of ADEsdisclosing errors, including their own.January 2015: The chief executive offi-are preventable. Employees know that they retain profes- cer (CEO) of a community healthcare sys-Potential adverse drug events: Thesesional accountability, but should not betem is reading the National Patient Safety events are defined as medication errorsheld accountable for system failures overFoundations (NPSF) report Not Enough that do not cause any harm because theywhich they do not have control. TheyChange Since to Err is Human. The report were either intercepted before reachingdo not tolerate clear risks to patients orstresses that, although some patient safety the patient or because of luck. gross misconduct. improvements have been made since the Ameliorable adverse drug events:Medication reconciliation: The process1999 report, both the pace and scale of These events are defined as those inin which clinicians review patients med- improvement have been slow and limited. which the patient experienced harmications at the time of transfer to anotherThe CEO schedules a meeting with represen-from a medication that, while not com- level of care or discharge and comparingtatives from all levels of staff, not just manag-pletely preventable, could have beenthem with medications prior to hospi- ers, to discuss the report, analyze safety data, mitigated. talization or transfer in order to identifyand identify interventions to increase safety.Adverse drug reactions: These eventsand address discrepancies. Nursing consideration: The Institute of occur when patients experience an ADEMedication safety: Freedom from acci- Medicine has been renamed the National even when medications are appropri- dental injury during the course of medi- Academy of Medicine (NAM). Since the term ately prescribed and safely administered.cation use or administration. Institute of Medicine is often used in rela-Adverse drug reactions are also referredRisk management: Clinical as well astion to its publications on medical errors, this to as nonpreventable ADEs, and arebusiness techniques used to prevent orcourse uses the term Institute of Medicine commonly known as side effects. decrease the risk of injury to patients,for the purpose of this section. However, it is Other important terms related to medi- staff, and visitors. It also involves tech- important for nurses and other healthcare cation safety as well as overall patient safetyniques to prevent or reduce organiza- professionals to be aware of the name change.include (Center for Patient Safety, 2018): tional losses and retain the organizationsThe IOMs reports on patient safety con-Bar code: A graphic representation ofassets. tinue to shake the healthcare community and data that can be scanned to provideRoot cause analysis (RCA): A pro- the general public. Just what is the IOM? It is access to various databases. cess used to identify factors that causeda nonprofit organization established in 1970 Close call: A situation that did not causeor contributed to adverse events oras a component of the U.S. National Academy harm to the patient but came close toother critical incidents. RCAs are con- of Sciences (NAS). The NAS is a nonprofit, becoming an error that could have leadducted using a specific, written proto- self-perpetuating society of distinguished to patient harm. Close calls are alsocol as a guide so that a detailed accountscholars engaged in scientific and engineering www.elitecme.com |2020| LEADERSHIP GUIDE 11'