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South Texas Veterans Health Care System (STVHCS)

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South Texas VA HRO Journey: Anticipate Risk

A nurse is standing in front of a cabinet full of medications

Nurse Kankiza Wegman stands in front of an Omnicell which holds medications and other items on the unit. Using the 10 rights of medication administration, she found a delivery error and corrected it, preventing any patient harm. She was recognized with a patient safety award. (VA photos by Steve Goetsch)

By Steve Goetsch
Monday, June 17, 2019

The Audie L. Murphy Memorial Veteran’s Hospital in San Antonio is one of 18 VA facilities chosen to lead VHA’s High Reliability Organization (HRO) journey.

One employee that is taking the facility toward that goal is Gastro-Intestinal Cancer Navigator Kankiza Wegman. Wegman recently received a “Good Catch” Award for outstanding patient safety practices.

The backbone of patient safety, the National Center for Patient Safety, highlights a monthly theme. For the month of July, the theme is: “Anticipate Risk – Every Staff Member a Problem Solver.” No one exemplifies that more than Wegman.

Wegman was picking up a patient’s medication from the pharmacy to administer. Right away, she noticed something was wrong. The injection was labeled by the pharmacy to be delivered subcutaneously. Wegman says the nurses at Audie L. Murphy are always detail oriented. “My philosophy is to always ask questions if something doesn’t seem right or look right,” Wegman said.

She knew previously that medication was always administered through intramuscular injection. Kankiza used the 10 rights of medication administration. That many questions might seem time consuming but is a necessity for Wegman. “Before administering medications, it is very important to prevent harm by going through the 10 rights,” Wegman said. “When it comes to the safe administration of any medication you can never be too careful,” she added.

Kankiza’s next step was to verify that the medication was in fact, given by pharmacy to be delivered via the wrong route through the patient’s medical record. It was, and she conferred with the pharmacist to make the correction. The old meds were discarded, and she received the correct medication that was administered through the correct route.

Although the patient received the proper meds, her good catch wasn’t done in Wegman’s eyes. Wegman says not only does Audie Murphy hospital promote transparency and teamwork, she said they learn from any near-miss experiences.

Wegman also shares her knowledge and experiences as a member of the patient safety committee.

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