The last category, involves failures in some of the processes of healthcare. The first is the failure of communication. Communication is extremely important in healthcare. No matter how small the system is, the patient is still a part of a great deal of interaction. This situation can lead to problems in patient identification, leading to other more serious errors such as incorrect procedures or administration of dangerous medication (Registered Nurse 2002).
Another possible error comes from equipment failure. Hospitals have had problems with defective equipment, and it has led to many injuries and deaths. In fact, equipment Failure has become such a problem that the Safe Medical Devices Act was developed in 1990. This held manufacturers responsible for their products and put into place a tracking system to monitor defective devices (Cuthrell 1996).
The final potential for error in this category is an error in the system. A number of authors concur that many of the problems of medical errors are due in part to the current system (Denting 1984; Juran 1989; Al-Assaf and Schmele 1997). High workload, rapid organizational change, inadequate supervision, and a faulty chain of command are all characteristics of most major healthcare delivery systems. All of these characteristics pose potential problems when treating patients and are what many solutions have targeted (Rosner 2000).
Reaction and the Solutions
There is a lack of medical error reporting. Physicians and nurses do not want to report errors for fear they will be punished. We live in an environment of judgment that should be changed to one of learning. But to achieve this environment we have to "drive out fear" (Deming 1984). To minimize fear of retribution, there must be a sense of protection. Providing confidential and anonymous reporting is one way of doing this. Another way is to pass legislation that would extend peer review protections to data related to patient safety and quality improvement (Brarzler 2001). Reporting on errors would inevitably help in learning from them and may help prevent them from happening again.
Two main types of reporting systems have been proposed. The first type is a nation-wide system that focuses on errors that result in serious injury or death. The Institute of Medicine, as well as others, has proposed a center for patient safety. This center would be part of the Agency for Healthcare Research and Quality and would focus on setting national goals pertaining to medical errors as well as tracking such goals (Wahls 2002). It would also conduct research on medical errors, evaluate methods of reporting systems, and communicate findings (Stephenson 2000).
The second system is a voluntary; confidential system that is localized to each healthcare facility. This system would focus on serious injury and death, but also on near misses, as these are also part of the systems' problems (Kohn 2001). The key of this strategy is to improve patient safety by identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as encourage voluntary efforts, with the goal of making sure the system continues to be made safer for patients (Kohn et al. 1999).
Medical students are never really taught how to handle a medical error. They are instructed about the consequences of performing an error, but never really taught what to do if one occurs. As a result, after graduation many doctors feel it is best not to think about medical errors, which leads to underreporting of errors. Doctors also have very little training in coping with families affected by medical errors. This can cause undue stress and also can lead to underreporting. Medical schools should place more emphasis on medical errors and teach students how to cope with mistakes if and when they happen (Meyer 2001).
The National Patient Safety Foundation (2000), a multidisciplinary group founded in 1998, is aiming to improve patient safety and has identified several mechanisms for doing so. Besides their call for active reporting of medical errors, they are also concerned with increasing the body of knowledge on patient safety and the causes of medical errors with the goal of identifying mechanisms for applying this knowledge to the work environment. Their mission aims at increasing awareness on patient safety issues through research, publications, and advocacy.
Clearly, medical errors are a huge problem facing the healthcare industry. Solutions need to be implemented to prevent such errors. Many of the above proposed solutions come with large price tags and some break away from the traditional. However, medical errors affect the lives of people. They are not something to be taken lightly. Implementing the above solutions would prevent the injuries and deaths of many people. "If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes" (Richardson et al. 2000).
--Al-Assaf, A. F., Bumpus, L. J., Carter, D., & Dixon, S. B. (2003). Preventing Errors in Healthcare: A Call for Action. Hospital Topics, 81(3), 5-12.
Improving Patient Safety Through Provider Communication Strategy Enhancements
- Dingley RN, PhD, Catherine. Improving Patient Safety Through Provider Communication Strategy Enhancements. Agency for Healthcare Research and Quality's (AHRQ), 2018.
Reflection Exercise #5
The preceding section contained information
about solutions for preventing medical errors. Write one case study example
regarding how you might use the content of this section in your practice.
What are two types of proposed reporting systems? Record the letter of the correct answer the CE Test