Quality Improvement of Health
Introduction
The safety of patients is a priority among nurses and other health professionals that are tasked with taking care and treating patients in the healthcare system. Nurses are involved in the provision of health care in every area of the healthcare system on a daily basis(Ellis, R, &D Whittington1994). Their presence and sound knowledge base enable them to play a significant role in maintaining patient safety. Medical care in the United States of America and other states around the globe is complex at the personal level, at the system level, and at the national level (Boerner, 2016). Through their caution, nurses act to keep patients safe by identifying areas of risk and recognizing situations in need of improvement (Institute of Medicine, 2001). However, despite the amount of caution applied, different errors occur in the health care systems that facilitate safety problems of those patients who are affected. The presence of errors leads to risks among patients, which interferes with their protection leading to issues in their health care that result in increased length of stay in hospitals, injuries, more health problems, and in some cases death (Kalra, 2011).
There is a tendency to blame individuals for the errors that occur within a health care systems because it is emotionally satisfying than to blame or target institutions (Reason, 2000). However, no individual should be blamed for the different forms of errors that occur, because it should be the duty of the management to create a safety culture and ensure that there is no room for errors that interfere with patients’ safety. The study will review the different forms of errors including their causes and why individuals should not be blamed for them and assesses the role of management in creating a safety culture while establishing the strategies to be implemented to uphold the culture. This paper will define errors in the context of health care systems, outline the various types of errors, and explain why they should not be blamed on individuals but the respective institutions in which the caregivers work for or the management in the healthcare systems.
Different forms of errors in healthcare system
The common errors include skill-based slips and lapses, rule-based mistakes, knowledge-based errors,medication errors among others.Lack of effective communication and coordination of the health care team is one of the main causes of fatal medication errors but it can be prevenetd if effective strategies are put in place (Harris, 2014). Nurses who work in health care systems make errors and thus need more education to care for patients comprising the side effects, polypharmacy and medical interactions. A large number of errors occur in the nursing profession because of the failure by most specialists to use critical thinking (Iyer, and Aiken, 2001). The ability to think critically in different situations is vital to nursing practice because it aids in taking informed decisions. Critical thinking encompasses problem solving behavior which involves obtaining and evaluating information about patients before acting. This makes the nurse to be able to infer, set priorities and construct an effective plan that will be crucial in aiding the patient. The prevalence of nursing disclosure for errors tends to be under-reported by nurses who are widely acknowledged as a group that reports incidents more significantly than other health professionals, including medical practitioners (Noosheh, Ahmadi, Faghihzadeh & Vaismoradi, 2008).
Every year deaths associated with errors are reported in the US, for instance, an average of 195,000 people in the USA died due to preventable, in-hospital errors in 2002.“Errors are a cognitive phenomenon for the reason that they reflect human action that is a cognitive activity” (Hughes &Hughes 2008. Misses are also errors in the nursing profession for the reason that they are events and incidents that could have caused adverse consequences and harmed a patient, but did not because of the late precaution that might have been taken. Factors that are involved in misses have the ability to be factors involved in errors if changes are not made to disrupt them for producing errors (Hughes, 2008).
Skill-based slips in the medical profession are the common errors that occur when healthcare providers are carrying out their duty This are rule based errors in which the actions of the healthcare providers deviate from the current intention due to execution failures (Johnstone, 2009).This is inadequate human performance governed by stored patterns of preprogrammed instructions, it occurs when the specialists become so accustomed to what we do, it becomes second nature. When the nurses become too comfortable with their environment, they open themselevs up to errors from overconfidence.
Memory-based lapses are skill-based errors that result when nurses carry out a planned actions but forget vital details (Niemann, Bertsche, Meyrath, Koepf, Traiser, Seebald, & Bertsche, 2015). Action-based slips are also skillbased errors that occur during an action and are defined as the performance of an action that is not Rule-based. Medication error,this is an error that may come as a result of improper medication use when the medicine is in the control of the health care professional, patient, or consumer.“The types of medication errors patients are prescription errors, transcription and interpretation error, preparation and dispensing errors with correct prescription and administration errors” (Tzeng, Yin and Schneider, 2013).Because nurses are most involved in medication administration, the use of the bar-code technology and smart infusion pumps may have an impact on nursing practice. Nurses are most involved in medication administration, shortly before any adverse drug events may emerge and thus they have the unique role of detecting and preventing errors that occurr in the stages of prescribing, transcribing, and dispensing.Understanding medical errors is dependent on the perspective of individuals because both expert and non-expert individuals, includingpatients, have different perspectives toward what is considered as error. These differences are even observed among the individuals who have been trained to assess errors
Rule based errors are those in which the actions of the nurses or other specialists may run according to the plan but the plan may be inadequate to achieve an outcome that the professional desired.They are actions that much the intention of the specialist but do not provide the best solution for the problem (Disch & Bernstein, 2014). This errors arise in many forms which include; misapplication of a good rule by a specialist because of the failure to see a misapplication of such a rule. Secondly ,they may also arise from the misapplication of a good rule or the application of a bad rule by a specialist who wants to treat a patient. The specialist may commit the above errors because he/she posseses some pre-packaged solution to a problem which has been acquired through experience,training or even the availiability of appropriate procedures.It is simply inadequate human performance governed by stored rules accumulated via experience and training of the specialists. Forinstance, nurses are governed by procedures within their work environments and as individuals, they are also governed by the laws of our land. “Insufficient knowledge in medication could be a result of deficiencies in the basic nursing education”(Simonsen, Daehlin, Johansson & Farup, 2014).
Knowledge based errors occur in circumstamces whereby the solution to a particualr problem has to be worked out on the spot without the help solutions which are programmed.It is simply inadequate human performance which uis governed by analytical processes and stored knowledge that a specilist poseses. It occurs when nurses and other specialists in healthcare face a situation that they have never faced before and no stored rules to provide them with guidance (Latino, 2007). In such cases, nurses depend on their own knowledge and expertise to solve the situation because of the dynamics of the working environment. The dependancy on their own experience and expertise in exceptional cases that have no clear rules can lead to an error.
Experience and expertise are used less frequently than previously thought and may not always impact positively upon clinical decision making by nurses (Stubbings, Chaboyer, & McMurray, 2012). These errors, for instance, may occur when a specialist is trying to diagnoze what has gone wromg with a malfunctioning system. Nurses and other specialist are at risk of making boith knowledge based and rule based lapses because of the dynamics of the profession which require to treat each case independently. In addition negative knowledge can be seen as a mental warning sign that may aid an elder care nurse in anticipating a critical situation (Gartmeier, Gruber, & Heid, 2010).Deviations from hospital policy, with regards to the administration of a medication, is not classed as an error unless the nurse’s action also deviates from the clear intention of the prescription.
Causes of errors in healthcare
Some of the reasons associated with these forms of errors include the nursing practice environment and workforce issues, teamwork and communication, conflicts within the nursing profession, nursing perspective on patient safety, technology, and the culture of blame (Keogh, 2013).Work force issues like conflicts are one of the main causes of errors that are committed by nurses in their line of duty. If the work environment of the nurse is characterized by conflicts among other factors then the nurses are likely to make errors thus resulting too loss of lives if the error is extreme. Conflicts affect the workplace environment of the nurses in a negative way, hence making it hard for them to execute their tasks and duties efficiently. Conflicts have negative effects on the nurse and range from minor misunderstandings to controversies.
Conflicts among nurses are likely to take place under various circumstances as almost every situation has the potential of generating conflicts depending on the circumstances. The management and leaders of the nurses should be aware of antecedents that results to conflicts for them to resolve the conflicts effectively and avoid errors in the medical profession. Conflicts among nurses are mostly caused by personality differences, limited resources, blurred boundaries in job descriptions, competition among different departments unreasonable work expectations and poor communication (Shin, 2009).
Bad working conditions as a result of a bad environment are likely to affect the mental state of the nurse and thus make them to be susceptible to nursing errors. Nurses see the value of their work when they make a positive impact for patients, leaving them feeling better and this can only be achieved in conducive working environment (Wolf, 2012). They feel better when their patients respond positively and the management recognizes the good work that they are doing. Positive feedback from the management of hospitals helps to boost the morale of nurse thus helping them to carry out their work effectively. The management in healthcare facilitiesplay a crucial role in making a good working environment for healthcare professionals like nurses. A bad working environment which is characterized by conflicts affects the mental state of nurses and thus makes them to be susceptible to making errors. Nurses often did not adhere to guidelines or protocols in a bad working environment and thus the need for the existence of rules that are feasible to implement in a daily routine by clinical nurses. Interruptions have a deleterious effect on a nurse’s ability to safely administer medication, for instance, those caused by patients or staff members talking to the nurse and those caused because the nurse has to leave the process of medication administration to attend to another activity (Cottney & Innes, 2015).
Technology is another source of errors in the nursing field if it is not used in an effective way. Technology in the nursing profession has made it easier for nurses to document and keep records of their patients in a place that they can be safely retrieved (Keane, 2014. Technology has made it easier for nurses to effectively perform their duties which are cumbersome when they use the traditional means. Technology is being implemented as a tool to prevent healthcare errors but the misuse of it has led to an increase in nursing errors (Piscotty, Kalisch & Gracey-Thomas, 2015). Prescription and administration of medicine to patients can now be done with the aid of technological tools unlike before when it was done manually. The misuse of technological tools like machines that are used to support the life of patients can lead to errors which can even lead to the death of a patient.
Most nurses in the contemporary society are very passionate in using the technology for it provides them conciseness and less work. Pen and paper at the nurses’ station have been replaced by a computer in the patient’s room which is used to record data but the computers can be the main sources of errors if they are fed with the wrong information. Information communication technology and its applications are seen as tools to engage patients in self-care (Korhonen, Nordman & Eriksson, 2015). The use of technology in healthcare facilities has helped to solve many healthcare issues, forinstance, records which can now be easily retrieved. At the same time, it has also come with its disadvantages whereby any slight mistake made can cause loss of lives. Nursing errors are increasing with the advancement of technology in the healthcare setting because the nurses are over relying on technology to carry out most of the tasks instead of using their expertise and experience.Using technological tools in the nursing of patients can lead to failures as a result of new errors associated with the technology (Daker-White, Hays, McSharry, Giles, Cheraghi-Sohi, Rhodes & Sanders, 2015).
Culture of blame, this is another factor that has led to an increasing in nursing errors.Blame shifting among nurses has become rampant in the contemporary society because no one wants to admit a mistake. A culture of blame that has been nurtured in the nursing profession has acted to exacerbate human errors in the profession. The safety of patients lies in effective communication between patients and health care staff or between the different staff involved in the care of an individual patient.
Reasons why individuals should not be blamed for the errors in healthcare
The management in healthcare facilities should take accountability of the errors that occur in the line of duty of the nurses because it is the working environment that results to such errors. The errors should not be blamed on individuals because most of them are as a result of the negligence of the administration to act on time. The management is tasked with providing a good working environment for nurses to ensure that they are not mentally affected while in the workplace. Continuous training is good of nurses because of the dynamics of the profession in which changes in the medical field keep on occurring. The management can use a number of strategies to ensure that human errors are mitigated when nurses are carrying out their duties. Supportive organizational factors such as good interdisciplinary communication and collaboration, adequate staffing levels, staff education and training, and access to information helps to reduce both errors (Flynn Liang, Dickson, Xie, & Suh, 2012).
Strategies that the management should implement within a health care system to prevent the errors from occurring include, building a safety culture, leading and supporting staffs, integrating a risk management activity, promoting reporting, involving and communicating with patients and the public, learning and sharing safety lessons, and implementing solutions to prevent harm (Apold, Daniels, & Sonneborn, 2006). The strategies will help in assessing the different measures that the management within a hospital setting should implement to uphold a culture of patient safety while avoiding the various forms of errors. The management and leadership of any health facility should guarantee nurses the needed resources and possibilities to work without interruptions in order to implement safer medication practices (Härkänen, Turunen, Saano & Vehviläinen-Julkunen, 2015).Preventing errors in the medical field when treating patient is a serious question of management workforce and safety culture issues (Metsälä & Vaherkoski, 2014).
Building a safety culture, this is the first step that the management should take to eliminate the human errors that have become so common in the nursing profession. A culture that is devoid of conflicts and blame shifting provides a good environment for nurses to carry out their duties in an effective way and thus avoid blame shifting. Safety culture will ensure that both the patients and the specialists that are tasked with taking care of them are well trained and have the requisite skills to accomplish their duties.Leading and supporting stuff, a strategy by the management to provide some services and support their staff is crucial in ensuring that nurses carrying out their functions effectively. This acts as incentives and boosts the morale of nurses so that they can discharge their duties in an efficient way and act with precision to avoid errors. The management should also remove the requirement for nurses to perform other tasks at the same time as the medication round, reviewing the procedures around administration of ‘when required’ medication, and ensuring that nurses’ workloads are kept within acceptable limits.
Involving and communicating with patients and the public is another vital step that the management of healthcare facilities can take so as to minimize human errors. Patients are the main victims who are affected by the errors which are done by nurses and other specialists in the healthcare profession. Public awareness on some issues that are related to good healthcare can help to minimize the effects of the errors that are committed by nurses. An informed public is a health public for the reason that they can easily take precaution when a human error occurs when a specialist is carrying out his/her duties. The management should come up with a strategy that will help the public to be informed on the dynamics of the nursing profession. A safety lessons should also be designed in such a way that both the specialists and the general public are informed of the errors that are likely to occur in the nursing profession. This will help both the public and the specialists in the field to take precaution when handling delicate situation that require utmost precision.
Patient safety depends on nurses paying attention to their patients’ clinical conditions and responses to therapies, as well as potential hazards or errors in treatment. Lack of attentiveness can be caused by system level problems such as understaffing, high staff turnover, or sudden shifts in the acuity levels of patients without an increase in nursing staff (Woods, and Doan-Johnson 2002. The management should find solution that will help to prevent harm to both the patient and the nurse if an error occurs. A specialist may fail to prevent a certain error but if the management has put in place safety strategies then the effects of the error can be minimized. The management should conduct a monitoring phase to scrutinize ward-specific habits of the drug-handling processes in sufficient detail to subsequently tailor targeted interventions. A monitoring phase will be necessary for the reason that medication errors may differ from one ward to another even in the same health facility. A survey is more appropriate in detecting knowledge deficits. The management can also introduce training courses by a clinical pharmacist should be implemented in daily routine and should contain all relevant details of drug-handling processes.
Conclusion
Error-free performance is a standard that is expected of medical professions; however, nurses and other specialists in the field are by no means infallible from committing mistakes (Valiee, Peyrovi & Nasrabadi, 2014).Skill-based slips and lapses, rule-based mistakes, and knowledge-based errors all occur as a result of various factors that characterize a specific health facility. Individuals should not be blamed for them because it is the role of the management to create a safety culture and establish strategies uphold the culture. Most of the errors that occur are caused by factors that are within the workplace environment, for instance conflicts, most intrathecal chemotherapy errors involve the accidental injection of vincristine; however, all of the Vince alkaloids all of the errors that occur can be easily prevented if effective measures are put in place (Smith, 2009). Many errors that occur in the treatment of patients in healthcare facilities can be prevented if the management takes actions and stop looking at them as individual based. The management is to be blamed for the errors because it is the one that condones an environment in which such errors occur.
References
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