4. Identify which causes, when removed or changed, will prevent recurrence . Finding root causes will lead to the next step of evaluating the best method to change the root cause. This will allow for developing a more efficient procedure to put in place. This is commonly known as corrective and preventive action. 5. Identify effective solutions . An effective solution is one that prevents recurrence, is within one’s control, meets the goals and objectives which have been set forth, and does not cause other problems. 6. Implement and observe the recommendations . When the recommendations are implemented and subsequently observed for a period of time, it will become more obvious what the real solutions are to ensure effectiveness (Singh et al., 2023). was originally developed outside of healthcare by reliability engineers in the late 1950s to study problems that might arise from malfunctions of military systems. However, today FMEA is utilized within healthcare as a way to assess risk of failure and harm in processes and to identify the most important areas for process improvements (IHI, n.d.). ● 32% more for metabolic problems associated with medical errors, including kidney failure or uncontrolled blood sugar—($11,797). ● 25% more for blood clots or other vascular or pulmonary problems associated with medical errors—($7,838). ● 6% more for wound opening associated with medical errors—($1,426).” Summarizing who is responsible for costs There has been a longstanding call for further analyses to help hospital leaders evaluate the costs associated with medical injuries—and put a price tag on clinical interventions that could help prevent adverse events in the first place. Mello et al. (2007) reported the following facts and figures: ● “A review of 14,732 medical records from 24 hospitals in 1992 uncovered 465 medical injuries, including 127 negligent injuries. ● On average, hospitals absorbed $238 of injury-related costs for every patient admitted that year. They externalized, or passed on, $1,775 in injury-related costs per admission. ● Among the 24 hospitals, malpractice premiums amounted to an average of $123 per patient” (p. 860).
2. Gather data/evidence . This part of the process requires a collection, or a sample of data related to the problem. This will assist in conducting a root cause analysis to identify the reasons why the problem exists. Gathering data and evidence will form the basis for determining solutions to prevent a recurrence of the causes and ultimately lead to preventing the problem in the future. 3. Identify the fundamental relationships associated with the defined problem . The most common element of RCA methods includes asking why the error occurred, recording the answers and considering the possible cause behind each of these answers. RCA attempts to identify contributing factors and all causes, proceeding until the desired goal of finding the “root” cause is reached. Failure mode and effects analysis The Institute for Healthcare Improvement states that a Failure Mode and Effects Analysis (FMEA) is a “systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change (IHI, n.d.). FMEA Costs of medical errors Medical errors carry a high financial cost. The IOM estimated that 400,000 preventable adverse events occurring in the hospital cost the nation $37.6 billion each year—including about $17 billion associated with preventable errors. The extra medical costs of treating only drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year (Van Den Bos et al., 2011). This includes 800,000 in long-term care settings, and roughly 530,000 occurring just among Medicare recipients in outpatient clinics. This estimate does not take into account lost wages and productivity or additional healthcare costs. About half of the expenditures for preventable medical errors are for direct healthcare costs. Like the physical and emotional harm caused by medical errors, the financial consequences do not stop at the hospital door. Hospital costs Studies that focus only on medical errors occurring during the initial hospital stay may underestimate the financial impact of patient safety events by up to 30%. These additional costs are for surgery patients who experienced the following medical errors compared with those who did not experience a medical error scenario, as reported by Relias Media (2008, n.p): ● “33% more for nursing care associated with medical errors, including pressure ulcers and hip fractures— ($12,196). Advancing patient safety requires a shift from reactive, piecemeal interventions to a total systems approach to safety in which safety is systematic and is uniformly applied across the total process (Rodziewicz et al., 2023). A total systems approach would require a prioritization of a safety culture by leadership throughout the healthcare continuum. It would mean addressing both the increased mortality and substantial morbidity that safety failures cause. Leadership would have to prioritize the well-being and safety of the healthcare workforce. System processes would need to re-designed to avoid heaping more, potentially disjointed, initiatives onto an already stressed delivery system and caregivers. Meaningful advancement in patient safety can occur only when a total systems approach underpins improvement initiatives.
PREVENTION OF MEDICAL ERRORS
The NPSF identified the following eight targeted recommendations for developing a total systems approach to safety: 1. Ensure that leaders establish and sustain a safety culture. 2. Create centralized and coordinated oversight of patient safety. 3. Create a common set of safety metrics that reflect meaningful outcomes. 4. Increase funding for research in patient safety and implementation science. 5. Address safety across the entire care continuum. 6. Support the healthcare workforce. 7. Partner with patients and families for the safest care. 8. Ensure that technology is safe and optimized to improve patient safety.
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Book Code: MFL1225
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