how does JCHAO Patient safety goals prevent medication errors?

[sginformatics]

]The scenario involves a patient receiving a double-dose of insulin while hospitalized and efforts by two nurses involved in the double-dose incident to conceal it. The patient reported the incident to administration, and the nurse's employment was terminated. Termination resulted not because the nurses made the error, but because they concealed making the error through inaccurate documentation and dismissal of the patients concern that an error had even occurred. Would the PSG's have helped avoid this situation?

[TakeOne]

Only one nurse was terminated for this? Both should have been.

[j621d]

Is this a hypothetical question?

[StephRN08]

They would have DEFINITELY prevented this error! According to TJC, all high-alert medications are to be independently double checked by 2 RN's. This would include insulin. This means that both RN's must look at the order, making sure that the blood glucose level and dose are correct, and checking the insulin and units on the syringe or pen. In my facility, we have to physically do this at the bedside - makes sense right? If you do these steps and both parties are paying attention then an error will not occur. However, you have the instances where one nurse was not paying attention and the other did not catch the error.

As another poster said, I am surprised that the other RN did not get terminated as well. This goes against the basic duty of a nurse to be accountable for their actions. It is also unethical and illegal.

[canoehead, BSN, RN]

They would have DEFINITELY prevented this error! According to TJC, all high-alert medications are to be independently double checked by 2 RN's. This would include insulin.

There were two nurses involved so I assume having a double check did not prevent the error.

[brownbook]

I really don't understand the question. I know what JCHAO is. And patient safety goals??? Is that the same as the six rights of medication administration?

I guess what I am saying is a nurse doesn't have to know acronyms, JCHAO, or "patient safety goals," to administer meds safely. Insulin has been a two nurse double check drug for many years?

As to trying to hide or cover up the mistake, that is just plain wrong, something they should have learned at their parents knees or in kindergarten?

[April, RN, BSN, RN]

We would need more information about the situation. Hospitals have policies in place that comply with Patient Safety Goals. The PSGs couldn't prevent the error if the nurses weren't following policy and then tried to cover it up.

[nursing6207]

The hospital that I work at. Nurses will just turn to others and say "I need 5 units of novolog. Then another verifies and they go on there merry way. The other nurse never signs anything with you. So, therefore in the court of law the other nurse could deny it, or they could say "well it wasn't documented." I have tried to bring up my concern about this but was just blown off by our nurse educator and NM. Sooo.... what do I know.

[regularRN]

Hmmm... I'm thinking a double dose of insulin and the patient was conscious such that they could report the incident?