Staff support error

Few organizations have put staff support service into practice in an organized and effective way or fully understood the need for such a service. In Waterman s study in the United States, 90% of dinidans stated that their organization did not provide adequate support for stress due to medical errors. Brigham and Women s Hospital in Boston is an exception, the home of a remarkable experiment in both patient and staff support that has its origins in a near disaster in 1999 in which Linda Kenney, the founder of Medically Induced Tramna Support Services, experienced a grand mal seizure during an operation for which the anaesthetist, Frederick van Pelt felt responsible. His initial experience sets the scene ... 

We support the intelligent choice of medications based on rational reasons, but avoid the position that all medication is bad, serving only as a substitute for adequate staffing. In this context, there is a great deal of trial and error in dosage adjustment, and there is no substitute for close monitoring in conjunction with frequent feedback from nursing staff. 

Supporting the safety staff is necessary to fully appreciate the cognitive backgrounds of the human error model, and to ensure an objective and uniform approach in describing, classifying and interpreting the reported events, ... 

There is continued focus on adverse drug events and medication errors. Processes must respond to actual or potential adverse drug events and medication errors and properly report them internally and externally (e.g., to the FDA, ISMP, or USP). Other standards address how adverse drug events and medication errors should be addressed to improve systems, support staff education and training, and minimize the risk of medication-related errors and adverse events. 

Minor amendments - also called administrative amendments - do not have to be approved by the ethics committee or RA, although most research sites choose to notify the ethics committee of such changes on a periodic basis. These would include, for example, typographical errors, amended contact information, appointment of new support staff... 

An analysis of self-reported interventions by hematology-oncology pharmacists and staff was also performed to document pharmaceutical care interventions over a period of approximately 8 months at the Walter Reed Army Medical Center.The interventions were analyzed to determine the types of interventions that are most frequently performed, prescribing errors encountered, medication cost avoidance that resulted from the interventions and types of interventions that are associated with medication cost interventions, and intervention acceptance rate by physicians. Interventions were entered into a personal computer and analyzed using CliniTrend Web Support System software (ASHP). Medication cost avoidance was determined if less medication was used, an equally effective but less costly medication was used, or a medication that could not be reused was not prepared. 

Supporting staff after serious incidents 199 The error and the reactions of those involved... 

People, organizations and culture vary enormously in their approaches and response to error and attitudes to error are changing. Hopefully, as patient safety evolves, healthcare staff will be able to be more open about error and more open about their need for support when errors do occur. While there is little formal guidance, and almost no research on this topic, the following suggestions may be useful. 

Chapter 9 Caring for patients harmed by treatment, 171 Chapter 10 Supporting staff after serious incidents, 192 SECTION FIVE Design, Technology and Standardization Chapter 11 Clinical interventions and process improvement, 211 Chapter 12 Design for patient safety, 230 Chapter 13 Using information technology to reduce error, 246... 

A sample of 475 staff from 10 hospitals in Costa Rica, Gimeno et al. (2005) found that safety culture was related to self-reported work-related injuries. Another study of 789 hospital-based healthcare workers in the USA, found that experienced blood and body fluid exposure incidents for workers were lower when senior management support, safety feedback and training were perceived favourably (Gershon et al. 2000). In Japan, reduced needle-stick and sharp injuries to hospital workers were associated with safety culture factors, such as being involved in health and safety matters (Smith et al. 2010). In our Scottish hospital sample, we collected information on self-reports of worker injuries, as well as observed errors affecting patients. 

Set the expectation for timely and interdisciplinary error and near miss investigations with an emphasis on patient/family impacted by the error the broader institutional implications of and learning from the error and the support of staff at the sharp end (closest to care). 

Lack of training. Projects, being discontinuous phenomena, are naturally associated with discontinuous employment and the use of new staff. Training needs and the associated time-lags easily lead to the use of relatively untrained staff over peak periods. All project personnel are involved, not just data input clerks. For instance, a site storeman who understands neither the need for meticulous input nor the consequences of error - but does understand the need to issue materials promptly under pressure - can and will reduce a computerized materials management system to irreversible chaos. Unreliable software support staff Software developers may understand that they are well-positioned to make themselves... 

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