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The Joint Commission (TJC) Sentinel event alerts 42 and 54 which are related to the unintended consequences of Health IT.
Video: Safe health IT saves lives
Sentinel Event Alert 42: Safely implementing health information and converging technologies.
https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-42-safely-implementing-health-information-and-converging-technologies/
Sentinel Event Alert 54: Safe use of health information technology.
https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-54-safe-use-of-health-information/
Select one of the following healthcare and technology-related patient safety errors;
A pharmacist enters a medication order on the wrong patient due to having multiple screens open in a pharmacy application.
A nurse administers a medication to the wrong patient due to a missing armband.
A chest X-ray order was entered into the electronic health record for the wrong patient accidentally clicked. The person entering the order noticed the error right away and promptly discontinued the order, but not in time for the X-ray technician to see that the order was withdrawn. The technician performed the test on the wrong patient.
The pharmacy received an order to dispense an antibiotic and pain medication postoperatively for a patient in outpatient surgery. Both medications are contraindicated for patients with known allergies to the drugs. There was no allergy information for the patient entered into the pharmacy system. The information about the patient’s allergies did not cross over from the electronic health record.
The surgeon tried to access a patient’s radiology study from the picture archiving and communication system (PACS) system in the operating room (OR). The display would only show a blue screen. The patient’s time under anesthesia was extended while the information technology technician tried to get the computer display to work.
A nurse overrides an alert from the medication dispensing machine and withdraws the wrong medication. The nurse administers the wrong medication, and the patient subsequently dies.
Utilizing the fishbone diagram template, a Fishbone diagram outlining the potential causes of the selected error;
pages APA 7th formatted paper detailing a remediation plan that addresses technology, safety culture, process improvement, and leadership concerns. Utilize at least three (3) scholarly resources to support your recommended remediations
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