Patient safety is a vital part of our health care system; it helps define quality health care. A challenging issue is keeping our patients safe because medical errors in the workplace can and they do happen. Who is responsible for taking proper measurers to ensure patient safety? Is it the nurses, physicians, administrators, society or patients themselves? All these entities are responsible for making sure the patient has the safest possible outcome. Medical errors are prone to happen so this worldwide issue will never be completely resolved however we as nurses need to make sure we are taking all appropriate actions to minimize the mistakes being made so that we are not putting our patients at risk.
Hence, this is a sentimental event because this unanticipated event resulted in death to a patient, not related to the natural source of the patient's illness. Therefore, the threat and error management model should be used to determine both training needs and organizational strategies to improve the management of threats to safety. What defenses in the system failed in this case? Can you construct a Swiss cheese analysis of the system defenses and what occurred?
The Institute of Medicine (IOM) published a report in 2000 that estimated there were around 100,000 deaths each year in American hospitals from medical errors. IOM results were mostly based on errors of comission. In ICUs, the errors of omission are much larger as compared to the errors of commission. The number of patients dying becomes even higher if these errors are included. The follow-up report by IOM in 2001, provided a direction towards the need for making the basic changes in the health care delivery.
As stated in the health and safety at work act etc. (1974), all healthcare staff are legally required to take reasonable and practical safety measures to protect themselves, other staff, and anyone else who may be at risk within the workplace. (HM Government, 1974) This means that all staff must adhere to the policies and procedures within their workplace and ensure that any information regarding risk to others is displayed clearly. This also coincides with the NMC’s code of conduct in regards to competence and knowledge.
Potential risks can come in all shapes and sizes and if left undetected, risks can develop into hazardous consequences. “Risk identification is the process whereby the risk management professional becomes aware of risks in the health care environment that constitute potential loss exposures for the institution” (Carroll, 2009, 15). Risk managers seek to gather information to warn about potential risks through an array of sources, such as generic occurrence screenings (patient records, incident reports, etc.), patient surveys, incident reports and claims, state licensure surveys, the organization’s infection control and performance improvement units, The Joint Commission and other similar group surveys (the National Committee of Quality Assurance Surveys, liability insurers, risk management consultants), contracts, and last but not least informal discussions with managers and staff. Spotting risks before they happen is key (Carroll, 2009,
I have work as a certified nursing assistant in the surgery unit and we have already implemented most if not all these patient safety measures. As a nurse, I will continue to practice and perform these safety measure that I have learned from my colleagues. Any patient that enters my unit will be asked to identify themselves. Patient will be asked to say their name and date of birth, while I make sure that their information is accurate on their arm band. Next step in the process, is to attain a medical history, from their current medication, health history and any allergies.
Established in 2002 by the Joint Commission to address the issue of safety in healthcare were various patient safety goals which dealt with many safety problems the accredited organization might face including medication and communication errors. The Joint Commission has also established National Patient Safety Goals for accredited organizations to follow in order to encourage patient safety by reevaluating the sentinel events data collected every year and revising the goals by omitting achieved goals and creating new ones. Hospitals evaluated by the Joint Commission must demonstrate compliance with the NPSGs as part of the accreditation process (Ellis & Hartley,
I focused on each area of the healthcare organization and role of each person in the causation of the error and created a risk management plan by answering the below-mentioned questions as follows: Patient Identification Process " What specific patient identification processes and protocols are used? " Did the hospital staff verify the patient's identity? " Was the patient identified by a 3-point identification using a bar-coded wristband or any other means? Though both patients' problems were correctly identified in the emergency room, a proper protocol or identification process was not followed in the operation room holding area by the nurse.
The concern for safety has become a bigger and more important issue, and these two departments are forming a relationship. Although it has been the tradition for these two departments to work separately, they both have a common goal, to oversee the safety and excellence in healthcare organizations. Some smaller organizations have always had the same person control quality and risk and remained successful. These days, we are seeing a lot more collaborations, goal sharing, ad idea exchanging among these two groups (Perry, 2007). Risk management is critical to every organization.
Changes to lower the number of medical mistakes According to Media Health Leaders medical mistakes are the third leading cause of death in the United States. Hospitals today are making life threatening mistakes and are looking for a way to fix their ways of error. Three methods that would help lower the number of medical mistakes are the increasing patients’ engagement, improving physician guidelines, while decreasing faculty shifts hours. Being aware of your condition and diagnosis would help decrease the chance of experiencing a medical error, because you would have more than just the doctor involved in your overall treatment.
To create an environment where these errors are a rare occurrence, all healthcare professionals must dedicate themselves to implementing QSEN's six core competencies each and every day. These professionals must also speak up when they see room for improvement in their workplace. Regardless of the healthcare setting or demographic of patients, safe outcomes are the purpose of providing patient-centered care. Since nurses are the largest subgroup of healthcare professionals, their ability to make strides towards improved medication administration is undeniable. As the nursing code of ethics states, nurses have the duty to protect the health and safety of those in their care (Winland-Brown, Lachman, O'Connor Swanson, 2015).
This includes identifying potential hazards and taking action to eliminate or reduce them, such as reporting faulty equipment or ensuring that patients do not fall. It is important to be vigilant and observant
Understanding how human factors affect patient safety is relevant as it can help us be more aware of the prerequisites of clinical errors and minimise them (Hinshaw, 2016). Upon reflection, I realised that patient safety is greatly affected by various personal and workplace cultural factors. I believe we should promote a self-assessment technique that was developed by the aviation industry. The acronym ‘IMSAFE’ (illness, medication, stress, alcohol, fatigue, and emotion) can be relevant for us before we commence our work each day to ensure a patient safety culture (Muglu & Navratnarajah,
The non-professionals take care of the patient under the supervision of professionals. Patient’s safety is an essential aspect of nursing care that should be part of the culture of a nurse as she cares for her patients. This requires that the nurse behavior should be directed towards achieving total safety 0f the patients throughout hospitalization. It is imperative that a nurse leader should adequately check the safety culture that is in place in her working environment and articulates a strategy to guide personal approach as they work to improve the safety
However, there are limited studies that have addressed safety climate among healthcare workers (Gershon et al., 2000; Hahn and Murphy, 2008; Smith et al., 2013). The question is that why ones should discriminate patient safety climate against safety climate of Healthcare Providers such as nurses. The reason is that there are powerful laws that support patient rights and continues supervision is implemented for that. On the other hand, patients are vulnerable individuals so any unsafe behavior has a potential of leading to serious consequences. In the other viewpoint, indeed patients are customer and healthcare managers attempt to obtain their customer satisfaction, because of business competition and/or financial
Anwar, MD E-mail address: M_anwarabdo@yahoo.com Introduction Patient safety; a healthcare discipline, defined as ‘the prevention of harm caused by errors of commission and omission’ with special emphasis on reporting, analysis, and prevention of medical errors that often lead to an adverse health care event (1,2). People in any community are exposed to preventable medical errors; a rate that ranges from 20-42% (3). The undue consequences of such medical errors require studies focusing on patient safety, generally concentrating on hospital environments (4,5). The strategy of a safety patient culture starts with an evaluation of the present safety level in an institution (safety precautions implemented without proper assessment may be costly with unpredicted new risks) (6).