Main Question Post: Discussion 1 The Effect of “To Err Is Human in Nursing Patients rely on health care professionals and institutional organizations for their safety, quality, and well-beings. Nurses are the frontline at the patient bedside, supporting the physician diagnosis and carry out arrays of medical orders for our patients. The Institute of Medicine (IOM) released a report in 1999 titled: “To Err is Human” that revealed a significant amount of medical errors made in healthcare industries mutually conveyed and otherwise (Wakefield, 2008). Medical errors are projected to trigger more demise yearly than all other debilitating ailments combined. For approximately over a decade now patient safety and quality have grown to be a health
Medical professionals are liable for malpractice and could face consequences such as a lawsuit against them or being fired. These errors can be minimized by being more
Better Care: Transform the Patient Experience through sooner, safer, smarter Surgical Care. Safety Culture: focus on Patient and Staff
The Joint Commission is involved in making sure the health care facilities are providing the patient and family members of patients the effective and safe care that the patient needs and deserves. There is a close relationship between the National Patient Safety Goals (NPSG) and the results of the Joint Commission survey. If the facility were following the NPSG’s then the facility would have more of likelihood that the organization will receive a good survey results from the Joint Commission. There are serious consequences for the health care organization if the organization does not meet the benchmarks set by the Joint Commission. Multiple tools out there will aid this author in determining if the organization that this author works in is
Nursing Bedside Reporting, Patient Safety, And Satisfaction Scores The American Nurses Association estimates that up to 80% of serious medical errors involve miscommunication between caregivers when patients are transferred or handed off during shift report (ANA 2012). In the nursing profession change of shifts require the successful transfer of information from nurse to nurse to prevent medical errors and adverse events (Sullivan, 2010). Research shows that when patients are included and engaged in their health care there is greater potential to lead to measurable improvements in safety and quality of care.
Communication is an important factor in determining patient outcomes, patient experiences, and healthcare costs, both positively and negatively. In fact, communication breakdown accounts for two thirds of sentinel events, the most serious of errors reported to the Joint Commission, making it the leading cause of medical errors (Starmer et al., 2014). The Institute of Medicine (1999) conservatively estimates that between 44,000 and 98,000 patients die each year from medical errors. More recent estimates predicted this number to be upwards of 400,000 deaths annually, making medical errors the third leading cause of death in the United States (Makary & Daniel, 2016). Miscommunication and handoff errors are the primary point these errors occur.
The article reviews the development of goals as a result of an Institute of Medicine report that highlighted the number of patients harmed each year by inadequate hospital practices (Rajecki, 2009). The NPSGs are a top priority in patient care delivery today and have paved the way in increasing patient safety and thereby decreasing costs associated with inconsistent care (Rajecki, 2009). Most health care organizations are now addressing care in a transparent manner. Organizations are looking within to make sure best care practices are being performed and are involving patients and families in their health care goals to achieve better quality outcomes (Rajecki, 2009).
Problem of staff. In this case study, I found out there had human errors on staff. Human error is “A failure of a planned action to achieve a desired outcome” (Human error, n. d.). From the beginning part of the statement, we knew that the untrained anesthesiologist had make a wrong decision to accept the oxygen tank for the intention of saving Michael’s life. The human error made by medical worker In the human error classification, Reason (1990) said “Greater understanding of the why of human error is provided by a popular approach based, in part, on the distinction between whether the inappropriate action was intended or not”.
The concern for safety has become a bigger and more important issue, and these two departments are forming a relationship. Although it has been the tradition for these two departments to work separately, they both have a common goal, to oversee the safety and excellence in healthcare organizations. Some smaller organizations have always had the same person control quality and risk and remained successful. These days, we are seeing a lot more collaborations, goal sharing, ad idea exchanging among these two groups (Perry, 2007). Risk management is critical to every organization.
The Australian Commission on Safety and Quality in Health Care was developed in order to improve such services in Australia. Australia’s healthcare system is still developing. Each year, there are new appearing organizations, volunteering programs and campaigns, and private providers. The outcomes expected are gradually realized, and implemented in real life. Nothing could have been done without the help of professionals on the highest level.
Medication Errors in Healthcare The nursing profession entails many responsibilities that range from providing emotional support to administering medications that could result in death for those receiving care. Approximately 40% of a nurse's day consists of passing medication, a duty that sets their level of liability above many other healthcare professions (McCuistion, Vuljoin-DiMaggio, Winton, Yeager, & Kee, 2018). Despite today's advances in technology and nursing education, the frequency of medication errors is still staggering. To ensure that the benefits of nursing outweigh the risks, nurses look to the Quality and Safety Education for Nurses (QSEN) six core competencies for guidance.
In the article “Governing Board, C-suite, and Clinical Management Perceptions of Quality and Safety Structures, Processes, and Priorities in U.S. Hospitals”, talked about self-administrated survey assessing the perceptions of board members, C-suite executives, and clinical managers regarding quality activates and structures. This article mentioned about an instrument Hospital Leadership and Quality Assessment Tool (HLQAT), its concepts focuses on what and who are the quality and safety drivers are. This survey was collected from 300 hospitals, which were linked, to performance on the centers for Medicare & Medicaid Services (CMS) core measures. According to the article higher-performing hospitals appear to be more effective at conveying their vision of quality care and creating a culture that supports an expectation that staff and leadership will work across traditional boundaries to improve quality. (Thomas, 2014)
Speaking up for patient safety is becoming increasingly important
We must confess our mistakes because we can avoid making similar mistakes in the future and allow ourselves a chance to grow. However, sometimes nurses take advantage of their authority and autonomy. This leads them to commit professional negligence. According to Marquis and Huston (2017), “negligence is the omission to do something that a reasonable person, guided by consideration that ordinarily regulates human
It also strives to improve the safety levels for both patients and healthcare
Healthcare settings are very busy – we have to deal with multiple patients, multiple tasks and many distractions. Phones are typically ringing, family members want to speak to us, and alarms are alarming. Our thought process is interrupted and mistakes happen. For instance, take for example alert fatigue. It is a common contributor to error in healthcare.