Reporting experiences by Learning Design at UTS

2024-01-17 23:13:58 UTC

Case 1:

An IMS report on a violent patient towards a staff member led the way to introduce protocols on how to deal with patients where we were not in the centre of conflict. Working in a correctional setting, we have numerous measures in place to ensure safety but this incident still occurred. This led the way for not only management but the health team to come together and collaborate on a plan that would prevent this from occurring. So far it has been working which is fantastic.

Case 2:

Patient medication diversions had been a common trend and other patients were presenting to the clinic with reactions for taking medication that was not prescribed to them. A more stringent method of providing medication was put in place to prevent this which has been working effectively. This change started by numerous reports of the same thing .

Medication Incident - Positive outcome

2024-01-18 09:10:06 UTC

A medication incident occurred in the paediatric setting. Patient allegedly received an incorrect dosage. When the nurse discovered this error she immediately informed the prescribing doctor and it was investigated. Nurses and doctors worked together to identify where and how the error occurred. Patient family was informed.

Fortunately it was a clerical error and not a medication incident. A very effective strategy was implemented to ensure that each medication was manually entered into a log book. Although it consumed additional time, there has not been a medication incident since.

Anna

janekelleher1966 — 2024-01-19 01:15:37 UTC

I do complete IMS regularly in my workplace. Mostly for clinical near misses that are always related to staffing. I always try to make reporting a positive experience. I always tell junior staff the more IMs we submit especially with staffing our organisation will identify a problem in patient safety and ultimately improve ratios. I do believe in My LHS process of reporting. I have seen many scenarios from SAC1 to SAC4 where the organization has changed practices to prevent errors. Unfortunately, it often takes A HARM score 1 to change things.

Burden of reporting

2024-01-19 09:58:24 UTC

I was involved in an medication error incident. No harm came to the patient but the medication was an S8 and the incident was potentially harmful. The error was not picked up until shift change when the meds were counted and the two RNs actively tried to find a way to 'fix' it as the reporting process (Victorian Health Incident Management System (VHIMS)) was too labourious and they feared repercussion. Obviously the incident was reported and training was implemented to use VHIMS. After this training reporting increased.

Falls

jenniferapiggott — 2024-01-27 22:13:42 UTC

Falls occur, when particularly elderly patients arrive in hospital, are in unfamiliar environments and unwell, their risk is elevated. Despite multiple strategies in place to reduce the risk of falls, they still happen. The reporting of this becomes arbitrary for nursing staff. The feedback from my team is that it becomes a blame culture, what the nurse didn't do to prevent this fall, rather than it being about preventing falls and identifying gaps in our care. Reporting is important, however, long forms on top of the paperwork and process for managing a patient post fall is exponential. All the paperwork and reporting ends up taking away from patient care, where the nurse is placed in front of a screen instead of their patient.