Nurses and other caregivers who commit mistakes are often referred to as being on the “sharp end” of the error because they perform the actual procedure or give the medication that leads to a bad outcome. Traditionally, they received all the blame when a mistake occurred. Current error management strategies, like those discussed in “Chasing Zero,” try to change the systems that contribute to significant error.
provide an example from your practice or institution of a “Chasing Zero” improvement that helps prevent health care error (for example, by themselves, automated dispensing cabinets, e.g. Pyxis machines, were developed primarily for revenue capture and inventory control, not patient safety).
Samuel Merrit College
The documentary “Chasing Zero” reflects on the importance of quality care and patient safety. From the video, a child presents with jaundice, but the hospital fails to recognize immediate treatment. As a result, the child develops further complications such Kernicterus, which results in brain damage from jaundice (Quality and Safety Education for Nurses, 2014). This documentary focuses on families that have been negatively impacted by medical mistakes. It tells the story of a high-profile heparin overdose and how it turned the actor Dennis Quaid’s family become activists for patient safety.
Unfortunately, there were many devastating instances such as this, which could have been greatly prevented. In response to these tragic events, activists have introduced many best-practice approaches to minimize these occurrences. One instance is a new cleaning checklist developed from culture methods from other industries to reduce the risk of Staphylococcal infections. Another best-practice approach is the invention of a Pyxis medication dispensing unit, which is a form of medication management that includes barcode technology. This provides another safety check for the nurse as it implements the five rights of medication administration, and minimalizes any further medication errors.