Question

How can preventable medical errors be used as an illustration of maintaining patient safety and providing safe, effective care? Identify some of the possible barriers that nurses face when acting on what they believe to be the morally correct action in this particular case.

Answer 1

Preventable medical errors can be used as an illustration in maintaining patient safety and providing effective care as follows:

• Errors can be classified according to their outcome, the setting where they take place ( inpatient, outpatient), the kind of procedure involved (medication, surgery) or the probability of occuring( high, low)
• Incident reporting and documentation of near misses are described as useful sources of information
• Healthcare failure mode effect analysis (HFMEA) and root cause analysis (RCA) are seen as powerful methods for process analysis.
• means to increase patient safety are considered in the broader context of clinical risk management.
• New approaches in the field of medical errors are aimed at minimizing the recurrence of avoidable patterns associated with higher error rates.
• A system approach and a blame free environment, aimed at better organizational performances, lead to much better results than focusing on individuals.
• Use of technology, information accessibility, communication, patient collaboration and multiprofessional team work are successful strategies to reach the goal of patient safety within healthcare organizations.

Eg. Unnecessary tonsillectomies, have been harshly recommended since 1950s . However, The professions acted very slowly to limit this common procedure until public scandal, on the avoidable deaths of children, forced the issue in early 1970s.

Barriers that nurses face:

• Failures in communication sometimes relate directly to poorly written prescriptions.
• Disclosure of error to patients, families, and hospital collegues is a difficult process.
• A punitive method of incident reporting.
• Rare voluntarily reporting.