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Chasing Zero with Dennis Quaid

Running head: CHASING ZERO 2

Factors that negatively impact safety in a healthcare organization
In the video, Chasing Zero (Denham, 2010), mentioned several factors or
challenges that adversely impact patient and negatively impact a culture of safety. These
factors include communication, fear, manufactured products, environment, and the
healthcare system.
Dennis Quaid started off in the video explaining his incident when his baby twins
received 10,000 units per millimeters of heparin, instead of 10 units per milliliters.
According to an article in LA Times (Ornstein, 2007), the hospital staff lacked on
following the facilitys policy on verifying drug's concentration, therefore leading to an
unsafe administration of the overdose. According to the article heparin was the most
frequent and misused drug in the nation (Ornstein, 2007). This was partly due to the
manufactured products of the 10,000 unit and 10 units of heparin vials having a similar
look. Because of Quaids incident, he was able to raise awareness on healthcare safety
and take action, where now heparin comes with a safety tear off red tag.
One story in the video, Steven Rel, a father experienced the death of his son at his
home, hours after a minor surgery (as cited in Dehnam, 2010). He did not get any
information nor the hospital and caregivers reached . It had to take over a year and a
lawyer to get the information about what caused the adverse event of his son. This made
the patients family feel that their son did not mean anything to them or anybody. In this
story, there is a block of communication to the family which eventually ended up the
family seek out legal actions. By stopping all communication to family the hospital
showed fear; fear of losing or owing money and their reputation. Overall families, power
Running head: CHASING ZERO 3

of attorney, and patients themselves should be aware of procedures, conditions that had
cause or a potential adverse event in a timely manner.
In another story, Sue Sheridan experienced a similar incident in which safety in
the system failed, when her husbands malignant tumor was reported unnoticed (as cited
in Denhan, 2010). The final pathologist report appeared to be on file, but for some
reason no one could see it except for the pathologist. There was the factor of system
failure and communication. The system failed because possibly everything wasnt
check. The checklist was not completed and some points were skipped. This misshaped
led Mr. Sheridans life in jeopardy.
Another factor is the environment and surroundings that influence the system the
health-care workers work. It was noted in the video that mistakes are kept swept under
the rug. Nobody wanted to move forward with mistakes because of the fear of being
punished. It was mentioned by Carol Chancy MD, that sometimes people are punish
tremendously when they acknowledge mistakes. She continues by mention that staff may
see this punishment and want to keep any errors quiet (as cited in Denham, 2010). This
brings a vicious cycle, where errors can continue to happen. By keeping mistakes or
errors swept under rug avoids not fixing the system. As mentioned in the video when
people see the punishment the system continues to be broken and not safe.

Running head: CHASING ZERO 4

Positive actions or steps that can be used to decrease or prevent medical
errors or improve patient safety
According to the video, one of the positive actions to start with to decrease or
prevent medical error is leadership. The video stated, Great leaders take risk, confront
their fear to drive adopt for best practices to make it safe (Denham, 2010). Leaders
start from their errors and determining multiple factors to why the error happened.
Leaders help provide evidence base practice and promote research and do their own
research. Leaders can start taking action and adopting actions on improving patient
safety. One of the things leaders do is take part of a major goal and bring in a motivated
team in implementing increase quality care. For example in the video mentioned the
100,000 lives campaign. This campaigns goal was to save 100,000 lives by
implementing safe practices. Leaders need a motivated team, where everyone can work
together. Not just the healthcare staff, as well as everyone including housekeeping.
Another part take in steps to improve patient safety is participating and following
useful resources mentioned in the video like the National Quality Forum (NQF) and
TMIT (Denham, 2010). These resources provide evidence-based practice for healthcare
safety. The resource gives for health care facilities guideline and procedures that know
tha work in providing quality and safe care.
Another way to provide increase safety in the healthcare is to invest in
technology. The video provided technology such as the Computerized physician order
entry (CPOE) flight simulator (Denham, 20120). The simulator computerized system is a
way for physicians can test out prior to using on real life patients. This system helps
Running head: CHASING ZERO 5

provides a safety working by having error-checking such as on medication dosages,
routes, or reaction. Like the CPOE, many hospitals are also adapting in the barcode scan.
This is another computerized system that helps checks the right patient and provides a
safety gate on administering medication. Technology can be the one of the safety tool
that provides a checklist or steps on increase safer care.
Often nurses give report to each other at the nurses station. In Chasing Zero
(Denham, 2010), giving report off to the next nurse while in the patients room is another
method mentioned in the video to improve patient safety. There, the on coming nurse can
get a look at what the patient looks like, what current signs and symptoms they are
showing, what they are attached to and get an overall better clear picture and report.


Denham, C. (Excecutive producer). (2010). Chasing zero: Winning the war on
healthcare harm Retrieved from http://QSEN.org
Ornstein, C. "Dennis Quaid files suit over drug mishap." Los Angeles Times 5 Dec.
2007: 1-3. Dennis Quaid files suit over drug mishap . Web. 12 Jan. 2014.