What kind of precautions would be needed to avoid a repetition of this particular system failure?
Article: Smetzer, J.L. (1998). Leason from Colorado: Beyond blaming individuals. Nursing Management, 29(6), 4951.
In
the article it identifies 14 system failures that were present. 1. Language Barrier 2.Inconsistant procedure for
communicating prenatal care 3. Staff inexpirience and poor documentation 4. Nonstandard method of writing the drug
order 5. Insufficient drug information 6. Lack of a unit dose system 7. Insufficient information on infant injections 8.
Incomplete clinical information 9. Inconsistent independent double check system 10. No staff education before dispensing
nonformulary
drugs 11. Insufficient drug information and inadequate drug references 12. Unclear definition on nonphysician
prescriptive authority 13. Unclear manufacturing labeling 14. Conflicting information on IV and use of milky white
substances. CHOOSE TWO SYSTEM FAILURES AND COMPLETE THE FOLLOWING 1) For each failure write a page
explaining how the system failure contributed to the sentinel event of the article.1What
kind of precautions would be
needed to avoid a repetition of this particular system failure? From what discipline might this precaution emerge e.
g.,
nursing, pharmacy, medicine, nursing administration, hospital administration? 2For
each of the system failures 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 o the article or initiative, and if appropriate, attach a copy of
the article to the paper. RUBIC REQUIREMENTSystem #1clearly
identifies and explains the chosen system failure #2Describes
precautions needed to avoid the failure. #3 Identifies and provides rationale as to which discipline should
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