"Guilty? Or not ... "

Nurse Petra accidentally gives the wrong medication to Mr Jansen, a patient suffering from Alzheimer's. This causes him to suffer from heart rhythm problems.
Should we immediately point the finger at Petra? Or is there more going on in this organisation? Read more here!

What is happening here?

The healthcare sector has been under pressure for years! This leads to stress among healthcare workers, which increases the risk of errors and decreases the quality of work.

Nurse Petra accidentally gives the wrong medication to Mr. Jansen, who suffers from Alzheimer's. As a result he suffers heart rhythm problems. The doctor and Petra’s colleagues don't understand why. Until the head nurse checks the medication supplies and finds that one of the beta-blocker pills is missing and there is one antihistamine pill (against his hay fever allergy) too many ... The ‘culprit‘ was quickly identified!


Similar situations like this occur!

Only the question should not be who the ’culprit‘ is, but how we can prevent these kinds of mistakes.
When we look at this case from the MIOO perspective, we can draw the following conclusions:
PEOPLE (Mens):
The pressure of work may be too high. This type of error creates a ’finger pointing’ culture, i.e. an unsafe working environment. Can things be done more efficiently, which will reduce the workload and fewer mistakes will be made? This will make employees feel a lot better about themselves. They will dare to take more responsibility and will receive more intrinsic motivation.
The provision of information is not effective enough. Apparently, it was unclear which medication the customer should receive. Can this be clarified?
ORGANISATION (Organisatie):
No process was set up for dual verification drug check. It was only afterwards when checking the medication supply that it was found that something had gone wrong. Can the process be adjusted so that a dual verification check takes place?
EDUCATION (Opleiding):
Every nurse who is allowed to issue medicines must receive regular continuing training and be able to recognize the various medicines quickly. Which competences does a nurse require? At least what training must a nurse follow? What knowledge should a nurse keep up-to-date?

What is happening here?

EPAHS is different from other organisational consultancy firms. EPAHS is focussed on bringing organisations ’into shape’. EPAHS helps organisations become future-proof! For this we have a lot of in-house expertise that focusses on the pillars of MIOO (People, Information Management, Organisation and Education) and the integrality of these pillars! We believe that these pillars are inextricably linked!
Do you want to know what Epahs can do for you?
EPAHS is a team of experienced specialists. We have developed a unique formula that makes your organisation / company more successful, more sustainable, more profitable and more future-proof.


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