Discover and read the best of Twitter Threads about #radondavaught
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1/11 Welcome to this #CME #CNE #Tweetorial: Medicine During a Public Health Crisis: Just Culture in an Unjust World.
See CME/CNE info.: tinyurl.com/yv528p6j
#JustCulture #Healthcare #RaDondaVaught #MedTwitter
See CME/CNE info.: tinyurl.com/yv528p6j
#JustCulture #Healthcare #RaDondaVaught #MedTwitter
2/Per the Institute of Medicine (IOM), most medical errors arise from “faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them, rather than from reckless actions by individuals working within those systems.”
3/The just culture model serves as a guide for healthcare systems by incorporating features such as human factor design, error prevention, and steps to contain errors’ ramifications before they become critical.
#NurseTwitter like most of you, I've been reflecting on the #RaDondaVaught case. The only thing I'm emotional about is the loss of an innocent life. I think it is important to reflect on future practice implications now and take a long hard look at "just culture" 1/
First, we should examine two cases in the country that did not receive attention or support where a nurse was criminalized for fatal medication errors. It should be noted that this is a rare occurrence, but what is happening with RV has happened before 2/
Case A: In Madison, WI, a 16-year veteran nurse administered a lethal dose of an anesthetic (meant to be placed in the epidural line) and an antibiotic. The 16-year old laboring patient died. The nurse did not scan the med, check the med, and created an override in the Pyxis 3/
It is important to discuss the Omnicell issue in the #RaDondaVaught case. Many nurses are accustomed to Pyxis, where each medication bin pops open to dispense. Having used the Omnicell many times, the containers are open and next to each other. It is easy to select the wrong 1/
medication. Some of the bins have missing numbers and the flashing lights to help the nurse identify the medication doesn't always work or looks like the bin above the flash when it is indeed below. This is close to my heart because this has happened to my students before 2/
the only thing that prevented the error was the scanner in the room. There was no scanner in radiology. This case is also as much about the five rights as it is about other hot topics (like overriding, system failures, distractions, etc.). As much as we don't want 3/
