complete the required documentation and associated care (Härkänen et al., 2019). Technology failures The use of technology to help prevent errors is quite prominent in healthcare organizations (Rodziewicz et al., 2023). However, technical failures are not always obvious and are often present in adverse events (Thimbleby et al., 2015). Equipment failures include those involving medical devices, implants, pumps, and sophisticated devices. Inadequate instruction about how to use the medical devices can also lead to serious injury. Appropriate decision- making when purchasing new equipment, along with using maintenance checklists and simulating equipment failures when adverse events occur, has been instrumental in
two patient identifiers, such as name, date of birth, assigned identification number, telephone number, or other person- specific identifiers. The patient’s room number or physical location is not an acceptable identifier. Proper identification of patients should be performed before the initiation of any treatment, service, or medication provided is essential for patient safety. Organizational transfer of knowledge Organizational transfer of knowledge can involve deficiencies in orientation or inconsistent education for those at the “sharp end” providing patient care. This category of cause highlights the level of knowledge that team members need to perform their assigned work and focuses on how things are done in the organization. This is important for all staff, but especially for new, temporary, and “float” or per-diem team members. Interprofessional education and collaborative practice and ongoing education and development are critical in reducing this type of error (Bridgeman et al., 2018; Rodziewicz et al., 2023). Workforce Staffing patterns can influence medical error rates when physicians, nurses, and other healthcare providers have inadequate staffing or when staff supervision is lacking. In some circumstances inadequate staffing and high workloads impact patient safety because there is little time to This section reviews the components of a safety culture and describes tools used to identify, analyze, and report medical errors. Building a culture of safety A body of literature suggests a link between the culture of an organization and the safety of patients. Organizations associated with decreased harm to patients include the following characteristics: a strong culture that embraces teamwork, in which speaking up about concerns is the norm; dedicated systems, structures, and processes that allow for the sharing of concerns; and the identification of actions implemented that result in safety improvements before the act reaches the patient (Kilcullen et al., 2022). Essentially, a strong safety culture is linked to fewer adverse events, while an organization with a weak culture is associated with higher rates of adverse events (Amiri et al., 2018; Rodziewicz et al., 2023). In response to the 2000 IOM report and the subsequent attention to medical errors, the focus in healthcare is transitioning from blame to recognizing that errors can occur at any point in the healthcare delivery system. Making errors visible, studying their causes, and designing methods to improve the system represent a major shift in healthcare from individual blame to recognizing medical errors as a way to improve the system. According to the Institute for Healthcare Improvement (IHI, 2023), a culture of safety requires not only that employees work for improvement but also that they “take action when needed” (para. 1). Pressure to do the right thing comes from all directions, and inaction is unacceptable. Leaders must drive the culture of safety and create an environment in which team members believe that action will result in change instead of reprisals or mere inaction (Kerfoot, 2016). A culture of safety acknowledges the inevitability of error and proactively seeks to identify latent threats. Characteristics of such a culture include: ● An environment where individuals are confident that they can report errors or close calls and near misses without fear of retribution;
reducing errors (Thimbleby et al., 2015). Inadequate policies and procedures
Standardized and up-to-date policies and procedures are essential for promoting consistency with decision-making surrounding clinical practice (Finkelman, 2016). While the use of inadequate policies and procedures can be a significant contributing factor in many medical errors (Rodziewicz et al., 2023), poorly documented, nonexistent, or clinically inadequate procedures can lead to failures in care. A CULTURE OF SAFETY: IDENTIFYING, ANALYZING, AND REPORTING MEDICAL ERRORS
● Collaboration across ranks to seek solutions to system vulnerabilities; and ● Demonstrated willingness to direct resources to address safety concerns. (Kilcullen et al., 2022) To achieve the vision of an open, transparent, and supportive culture, the Lucian Leape Institute, established by the National Patient Safety Foundation, states healthcare systems must achieve five transforming concepts: 1. Transparency must be practiced in everything they do. 2. Care must be delivered by multidisciplinary teams working in integrated care platforms (chronic care, acute care, end-of-life care, etc.). 3. Patients must become full partners in all aspects of health care. 4. Healthcare workers need to find joy and meaning in their work. 5. Health professionals’ education must be redesigned to prepare new care providers to function in the new environment. (Leape et al., 2009) In a culture of safety, errors are viewed as opportunities to learn and subsequently improve the system. Several strategies, such as safety reports at shift changes, appointing a safety champion for every unit, designating an administrative patient safety officer, and conducting patient safety walk-rounds and safety briefings, are some approaches to building a culture of safety (IHI, 2023). Patient safety experts also believe that to be successful, individuals at all levels, from the board of directors to managers, care providers, and patients, must contribute to a culture of safety (American College of Healthcare Executives and IHI/ NPSF, 2017).
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Book Code: MFL1227
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