Do Not Use List: A Case Study

1. The physician in this video went against the patient's wishes. The nurses in the clip followed the physician's orders and participated in the resuscitation. What professional roles and/or attributes that we discussed in class did they ignore and how should they have responded in this situation? Describe specific examples of professional communication techniques they could have used.

The Joint Commission is part of the pharmacy laws and was formed in 1951 as a not for profit organization and is used for the safety of patients and pharmacy workers. The Joint Commission developed a “Do Not Use List” to help both the doctors and pharmacy workers take notice to the mistakes that can be made with just one mark in the wrong place or not on the prescription at all. There are many examples but just one is QOD and Q.O.D this is a difference of every day versus every other day, and could make someone have a hard time getting over an illness or becoming something different1. If a pharmacy tech thinks that a prescription does not look like it is written correctly, he/she should contact the prescribing

The Joint Commission is a not-for –profit organization. It’s a private nongovernmental program that is purposed for improving the quality of health care. The Joint Commission accredits more than 21,000 health care organizations in the United States. This document has created a standard and national patient safety goal in which health care providers must comply. A list was created do to the fact that many error has been made throughout the medical system. The Joint Commission brought forth, which is known as the do-not-use-list. This list contain many errors of words been misuse when it comes down to the medical field. When dealing with medication it’s very easy to make a mistake by a hand written prescription cause by rush handing writing

The Do Not Use List was created by the Joint Commission help reduce the numbers of errors related to incorrect use of terminology they issued a list of abbreviations, acronyms and symbols that should no longer

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

17. Work sensitively with patients and family carers, telling them who to report incidents of danger, harm and

Answer: As a part of a high-reliably organization, I am committed to 200% accountability and safety as the number one goal. Over the past year as an Informaticist, I have consistently advocated for patient safety and safe workflows. As an example, a new staff endocrinologist made a request to update the Insulin Basal Bolus Correction order set that was not evidence-based. I met with the endocrinologist to review the current practice guidelines per America Diabetes and Endocrinology Associations. During our discussion. the endocrinologist did not realize that there was the ability within the order set to make the desired changes to individualize the care and orders

As health care workers we are under a legal obligation to protect an individual from any kind of abuse, whether it is physical, financial, emotional, sexual or psychological .Legislation, policies and procedures exist to promote a safer working environment and reduce the potential for risks occurring. They are tailored for the needs of each setting, known and understood by employers and employees and reviewed on a regular basis.

In this article it talks about how the miss use of medical abbreviations should never happen. Like BT means bedtime but could be mistaken for BID which is twice a day. ISMP would like you to use bedtime so that there is no confusions. Another abbreviation that could cause a miss communication is HS which means half strength, which could be interpreted as bedtime. Which means they would be taking the full amount when they should only be taking half of the normal doses. Yes, I think that is very helpful to help cut down on all of the miss communication.

All identified risks should be reported to the nurse or the line manager on duty so it can be corrected/amended and a new risk assessment can be put in place. This also should be documented appropriately.

The following are the National Patient Safety Goals for 2016: improve the accuracy of patient identification, improve the effectiveness of communication of caregivers, improve the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk of health care- associated infections, and for the hospital to identify safety risks inherent in its patient population (Hudson 2016 page 2). Under each category there are specific goals, such

2012 Joint Commission Patient Safety Goals. (n.d.). Retrieved January 2014, from Captain James A. Lovell Federal Health Care Center: www.lovell.fhcc.va.gov/about/2012PatientSafetyGoals.pdf

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

Other actions that I would take is to discuss the patient scenario with the patient care committee, Pozgar states, “ The patient care committee reviews the quality of patient care rendered in the organization and makes recommendations for improvement of such care” (P.146). The

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient