16 hours ago · You just received a new patient who needs to be admitted to your unit, and you just finished medicating a patient with a narcotic injection with a dose greater than ordered. Clearly understanding medication errors may lead to patient injury and even death, explain why a clinician may choose to NOT report the incident. >> Go To The Portal
You just received a new patient who needs to be admitted to your unit, and you just finished medicating a patient with a narcotic injection with a dose greater than ordered. Clearly understanding medication errors may lead to patient injury and even death, explain why a clinician may choose to NOT report the incident.
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What is a Patient Incident Report? A patient incident report, according to Berxi, is “an electronic or paper document that provides a detailed, written account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting.” Reports are typically completed by nurses or other licensed personnel.
The fact that it is often difficult to decide whether to report suspected abuse does not negate one's professional and legal responsibility to protect children by doing so. Physicians are not responsible for determining whether maltreatment occurred, only for reporting reasonable suspicion.
According to a study by the US Department of Health and Human Services, 86 per cent of hospital incidents go unreported. Even more staggering, though, is the reason behind this. Staff did not consider 62 per cent of incidents as reportable, due to unclear incident reporting requirements.
Staff who continue to report the same or similar incidents can become demoralized, increasing the risk they will not report in the future. When (near) incidents and staff response to incidents aren’t accurately captured, the costs are high for individual practitioners as well as the healthcare system.
Not reporting medication errors limits opportunities to improve patient safety. Barriers to reporting medication errors and near-misses have been reported to include culture, the reporting system, management behavior, fear, accountability, and the harm to patients.
Fear of punishment and legal consequences in clinical practice has always been one of the barriers to error reporting. It is estimated that about 95% of medication errors are not reported due to the fear of punishment.
While many doctors under the guise of concern for patient welfare do not disclose medical error, such behaviour is not ethically justified. The fiduciary nature of the doctor-patient is such that the doctor is ethically obligated to disclose medical errors to patients.
Medication errors are detected by voluntary reporting, direct observation, and chart review. Organizations need to establish systems for prevention of medication errors through analyzing the cause of errors to identify opportunities for quality improvement and system changes (Morimoto, Seger, Hsieh, & Bates, 2004).
Conclusion. Errors and mistakes can occur in nursing, and it is important to reduce or prevent them; reporting helps to achieve this through the identification of patterns that are rectifiable. Nurses should never be afraid to report a mistake and it is their duty to improve practice and keep their patients safe.
Most hospitals currently rely on voluntary reporting. A 2011 Health Affairs study, however, found that voluntary reporting missed 90% of adverse events.
Do physicians have an ethical duty to disclose information about medical mistakes to their patients? Physicians have an obligation to be truthful with their patients. That duty includes situations in which a patient suffers serious consequences because of a physician's mistake or erroneous judgment.
Ethical issues. Several ethical issues can occur as a result of medication errors. These issues, harm to patients, whether to disclose the error, erosion of trust, and impact on the quality of patient care, are not mutually exclusive. Harm to patients is self-evident.
Except in emergency situations in which a patient is incapable of making an informed decision, withholding information without the patient's knowledge or consent is ethically unacceptable.
Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents' safety.
All medication errors, incidents and near misses should be reported to the duty manager to inform them what has happened and also what action has been taken to rectify the immediate situation and what has been done to prevent it happening again.
They prevent duplication of work, decrease errors and show efficiency level of the staff. Records and reports hold an important place in the process of educational administration.
Physicians reported that discussing the case with a knowledgeable colleague helped them decide whether or not to report suspicious injuries. The clinician's past experiences with CPS. Clinicians who believed that CPS involvement would result in a negative outcome for the child or family were less likely to report.
The number of children who are maltreated annually in the United States is difficult to document because: (1) definitions vary across tribal, state, and federal jurisdictions; (2) the standards and methods of collecting data vary considerably; and (3) many cases go unrecognized and unreported [5].
The level of suspicion required to report suspected abuse is not clearly defined. But, with the knowledge that physicians tend to underreport suspected abuse, the following recommendations are made to increase physicians' confidence in making appropriate reports: 1 Obtain continuing education regarding child maltreatment. Routinely seeking out local and national opportunities for continuing education related to child abuse and neglect can help you maintain a current understanding of child maltreatment. 2 Know reporting laws. Familiarizing yourself with the reporting laws and to whom reports should be made in your state (i.e., CPS or law enforcement) can lessen the ambiguity in the reporting process. 3 Consult with colleagues. Establishing collaborative relationships with colleagues to consult with regarding difficult cases can assist in the decision-making process. Physicians in private practice who do not have colleagues readily available may want to create a referral process with local agencies that have teams who make these decisions. 4 Know your local CPS staff. Forming relationships with your local CPS staff members can facilitate an open line of communication and establish a better sense of the guidelines used by the agency.
As a result of these actions, a child may have bruises, broken bones, burns, or internal injuries that document the occurrence, as well as imprints of the specific object used to inflict the injury (e.g., belt buckle, hand, and knuckles). In sexual abuse, an adult or older child engages a child in sexual activities such as fondling, intercourse, ...
Such instances present physicians with difficult decisions. It is not the physician's responsibility to determine the intent of the parent or caregiver, or whether abuse or neglect occurred.
A 2008 study found that pediatricians in an office-based setting do not always report suspicious injuries [4, 5]. Physicians from two national pediatric practice-based research networks were recruited and 434 reported information from more than 15,000 injuries seen in their offices.
Conclusion. The fact that it is often difficult to decide whether to report suspected abuse does not negate one's professional and legal responsibility to protect children by doing so. Physicians are not responsible for determining whether maltreatment occurred, only for reporting reasonable suspicion.