Patient Safety Critique
Smetzer, J.L. (1998). Lesson from Colorado: Beyond blaming individuals. Nursing Management, 29(6), 49–51.
In the article, “Lesson From Colorado: Beyond Blaming Individuals”, Judy Smetzer identifies 14 system failures that were present in the case of newborn Miguel. These 14 system failures were:
Incomplete clinical information
The language barrier
Inconsistent procedure for communicating prenatal care
Staff inexperience and poor documentation
Nonstandard method of writing the drug order
Insufficient drug information
Lack of a unit dose system
Insufficient information on infant injections
Inconsistent independent double check system
No staff education before dispensing non-formulary drugs
Insufficient drug information and inadequate drug references
Unclear definition of non-physician prescriptive authority
Unclear manufacturer labeling
Conflicting information on IV use of milky white substances
Choose two system failures from Smetzer’s list of 14, and complete the following assignment in no more than six typed, double-spaced pages:
For each system failure that you choose, write a page explaining how the system failure contributed to the sentinel event of the article. What kind of precautions would be needed to avoid a repetition of this particular system failure? From which discipline might this precaution emerge (e.g., nursing, pharmacy, medicine, nursing administration, hospital administration)?
For each of the system failures that you have chosen, find the most recent piece of evidence that demonstrates either research being done in this area or new recommendations to address this particular system failure.
Provide a summary of the article or initiative, and if appropriate, attach a copy of the article to your paper