Immediate response
What was the first thing the nurse did when the pt became unresponsive?
Called the rapid response team
Who was involved in disclosing the incident
Nurse, physician, charge nurse
Name one document needed to review the medication incident
EMR
MAR
Blood glucose
Hand written order
What type of medication was involved in the error?
Insulin
What change will help prevent unclear handwritten insulin doses?
switching to electronic prescribing
Which emergency medication was given to reverse severe hypoglycemia?
IV dextrose
What key approach must be used when speaking with the pt and family?
Honesty and transparency
People, environment and communication are categories apart of what?
Fishbone diagram
What specific error occurred when interpreting the physician's order?
A decimal point error
What safety step must be required for all insulin administrations?
mandatory double check by the charge nurse
Where was the pt transferred for close monitoring after stabilized?
ICU
What type of info was shared about the incident?
What happened, why it happened, and how the pt was being cared for
Objective, accurate events and reduces bias
Workload, unclear handwriting, and lack of double-checking are examples of what?
system contributing factors
Who is responsible for training and updating policies?
CI and QI team
Name one vital sign or assessment monitored after pt was stabalized.
Blood glucose
Neurological assessment
Vital signs
Risk management/patient safety team
Name one person who should be involved in the analysis
Nurse, physician, charge nurse, CI, QI team
The goal of analysis is to understand why the error occurred. Not to do what?
When will follow-up reviews take place to monitor progress?
4-6 weeks and 3 months
Which support was offered to the nurse after the incident?
Emotional support, employee assistance program, safety huddle debrief
What is important to maintain after the initial conversation?
Regular updates to Pt's family and to patient.
The 5 whys
The final root cause identified was a gap in what?
SYSTEM LEVEL GAP
insulin safety and verification policies
Name on way the change will be sustained long-term
Annual competencies, safety huddles, monitoring incident trends