Communication factors Miscommunication represents the most common cause of errors impacting the patient (Rodziewicz et al., 2023). Lack of clear oral and written communication among teams and between care providers and patients jeopardizes patient care. Miscommunication can occur across and within Inadequate information flow Inadequate information flow can affect the availability of critical information that is needed to influence patient care decisions. Patient transitions or movement across and within acute care settings, community settings, and the patients’ homes are times when patients are at increased risk of harm. For example, confusing and incomplete information and/or decreased sharing of information about the patient throughout the care continuum could lead to adverse events (Finkelman, 2016). A decentralized and fragmented healthcare system can result in poorly documented or lost information on laboratory tests, diagnostic tests, or medical Human factors Human factors, such as fatigue, illness, drug use, and apathy, can all contribute to medical errors. These factors can affect the ability of healthcare providers to follow policies, guidelines, and best practice protocols (Rodziewicz et al., 2023). For example, researchers of an international Patient-related factors Patient-related issues can include inadequate identification, incomplete patient assessments, incomplete patient information, and inadequate patient education (Rodziewicz et al., 2023). The Joint Commission’s National Patient Safety Goals (NPSGs) program for hospital accreditation went into effect on January 1, 2003. Currently, the Joint Commission (2023a) lists Goal 1 as “to identify patients correctly.” Included in the action steps is the use of at least 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 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 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 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 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
healthcare settings and among anyone involved in the care of patients. All members of the interprofessional team need to be knowledgeable about effective communication techniques that focus on patient safety (Interprofessional Education Collaborative, 2016). information, further contributing to medical errors. Investing in health information technology (HIT) to have a system that enables accurate transfer of patient information can enhance patient safety but can also present risks to patient safety. Errors can happen when the patient’s sociodemographic and health data are entered. Other patient safety issues can be related to the software and upgrades to the computer hardware. Implementation of an infrastructure to monitor and learn from near misses is extremely important to reduce errors (Meeks et al., 2014). study performed in 12 countries found that nurses working shifts longer than 12 hours, and those who worked overtime hours, reported increased incidents of poor quality and safety, along with care activities that were not able to be completed (Griffiths et al., 2014). treatment, service, or medication provided is essential for patient safety. Self-Assessment Quiz Question #2 A healthcare provider is getting ready to measure vital signs of a patient before beginning treatment. Which of the following mechanisms are appropriate to correctly identify the patient? Choose all that apply. a. Medical Record Number. b. Full Name. c. Room Number. d. Date of Birth. 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).
impact patient safety because there is little time to complete the required documentation and associated care (Härkänen et al., 2019).
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 reducing errors (Thimbleby et al., 2015). 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.
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