Accreditation

Hospitals continue to struggle with heparin overdoses

Accreditation Connection, September 19, 2008

Editor’s note: This feature explores problematic Joint Commission standards with expert advice from BOJ advisors. This month, Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor, is joined by guest columnist Eileen Willey, RN, MSN, CPHQ, PI director at St. Joseph Medical Center in Towson, MD, to discuss heparin error prevention. St. Joseph has decided to address risks associated with heparin based on lessons learned at other facilities.

Despite increasing media coverage and awareness in the field, errors with heparin—sometimes fatal—are still making national headlines. Are these problems latent errors or conditions?

James Reason created the term “latent reason” to define a situation in which failures occur due to flaws in the design of a process rather than a specific error causing the failure; it is a scenario, such as lack of clarity or multiple processes, that allows more opportunity for errors to happen.

So the trick here is to find the cause of these errors and develop methods to prevent them. Let’s take a look at some of the various failure modes and causes at the root of heparin errors.

Access the full story in the September issue of Briefings on The Joint Commission. Access is free for BOJ subscribers; nonsubscribers can purchase a copy of the story for $10 by clicking here.

 

 

Comments

0 comments on “Hospitals continue to struggle with heparin overdoses ”

 

Most Popular

Related Articles