Opportunities & Challenges with Patient Safety Goals

# 1

Opportunities & Challenges with Patient Safety Goals

Annerys Velazco

St. Thomas University

NUR 415 AP 1

Dr. Rosa Rousseau

08/04/22

 

The Joint Commission established the National Patient Safety Goals in 2003 as a program to promote quality and patient safety. The NPSGs were developed to assist accredited organizations in addressing specific patient safety concerns. The selected 2022 NPSG for this study is Goal 3: improving the safety of using medications (NPSG.03.04.01). In perioperative and other procedural settings, all drugs should be labeled, including medication containers, and other solutions on and off the sterile field. In this case, medication containers include syringes, medicine cups, and basins. In the clinical settings, the unlabeled medications and other solutions are usually unidentifiable. As a result, errors, sometimes fatal, have occurred as a result of drugs and other solutions being removed from their original containers and placed in unlabeled containers (Larmené-Beld et al., 2018). This dangerous practice is a direct violation of the basic principles of safe medication administration, and yet, it is common practice in many workplaces. Therefore, this NPSG goal ensures that there is labeling of all pills, medication containers, and other solutions in a process that is risk-reducing and is much compatible with good medication management practices. Further, the goal addresses a known danger point in the delivery and administration of drugs in perioperative and other procedural settings.

To fully achieve this goal there are various elements of performance that need to be achieved. First, the healthcare provider has to label drugs and solutions that are not immediately provided in the perioperative and other procedural settings. This is true even if only one medicine is utilized. According to Bowdle et al. (2018), in the sterile field today, the labelling errors usually involve the mixing of two liquids in labelled containers. As such, the approach that is necessary to prevent these errors, supported by 2022 NPSG goal 3, is straightforward and very simple and that is; correct and full labeling of all solution and drug containers on the sterile field in every procedural area, every time. The second element of performance is that labeling occurs in perioperative and other procedural settings on and off the sterile field when any medical solution is transferred from the original packing to another container. The basic function of a label in this case is to guarantee that healthcare provider and the patient can readily identify the medicine even if it has been placed in a new container. It is essential to note that, there may arise confusion between medications with similar names, labels, or packaging. This has been recognized as a major source of error among healthcare providers who administer medication to patients.

Overall, there has been many cases of medication errors that arise from poor labelling of drug containers which has prompted a national focus on unlabeled medication and solution containers by the Joint Commission and other relevant institutions. It is evident that healthcare professionals are aware of the risks that are linked to labeling of medication solution containers, especially in the preoperative settings. Hence, the recurrence of this error indicates that healthcare providers have lost sight of the risks associated with unlabeled products, have incorrectly believed the risk is justified and minor, or have forgotten to apply effective prevention efforts in all procedural areas. This brings up the aspect of normalcy bias which leads some healthcare providers to make an assumption that an error would never occur when drugs are poorly labeled or a solution is changed into another container. Besides, the unlabeled containers may also be considered as ‘someone else's problem,’, a phenomenon similar to bystander indifference in which people ignore a problem because they believe it is irrelevant to them, unlikely to happen, something they cannot remedy, or the responsibility of someone else to fix. Further, some providers assume that they have developed the ideal labeling techniques or are able to remember their medication only to discover that the task is onerous, error-prone, or unfeasible without system adjustments. To help identify this issue as significant, the Joint commission came up with the 2022 National Patient Safety Goals where they provide for proper labelling of medical containers in the preoperative settings.

References

Bowdle, T. A., Jelacic, S., Nair, B., Togashi, K., Caine, K., Bussey, L., ... & Merry, A. F. (2018). Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. British Journal of Anaesthesia, 121(6), 1338-1345. https://doi.org/10.1016/j.bja.2018.09.004.

Larmené-Beld, K. H., Alting, E. K., & Taxis, K. (2018). A systematic literature review on strategies to avoid look-alike errors of labels. European Journal of Clinical Pharmacology, 74(8), 985-993. https://doi.org/10.1007/s00228-018-2471-z

 

# 2

Jacqueline Brown

St. Thomas University

NUR-415: Health Care Issues 

Professor Rosa Rousseau

August 3, 2022

 

 

Opportunities & Challenges with Patient Safety Goals

Essential health services must be provided in a safe environment for patients. Preventing and mitigating injury to patients throughout health care is a standardized practice in nursing practice. Constant progress based on comprehensive training and experiences encompassing unfavorable situations is essential for quality health care delivery. Quality health care services should be safe, effective, and oriented to the needs of patients worldwide. Health services must also be timely, integrated, and efficient to reap the advantages of quality health care. Effective patient safety plans need well-defined policies, a capable leadership team, data to guide safety improvements, well-trained medical workers, and active patient participation. Delivery of quality care is in line with the realization of the 2022 National Patient Safety Goals. 

According to Carayon et al. (2018), it is a fundamental idea of systems engineering and human factors to look at the whole system rather than just focusing on a single component. The system’s components and interactions must be improved to achieve this aim. The entire system needs to be considered regarding patient safety practices like preoperative checklists. The check-in tool may favorably or adversely impact system aspects such as team communication and workflow. Engineering and human aspects are rooted in system design concepts, applied through user interaction and diverse analytical approaches in lifelong learning cycles with education and evaluation loops.

One of the 2022 National Patient Safety Goals is to reduce or eliminate mistakes in surgical operations. Systems engineering and health care differ significantly in culture, which is often overlooked or underappreciated. There is a tendency to blame patient safety accidents on the shoulders of individuals in the healthcare industry (World Health Organization, 2018). On the other hand, human factors aim to construct systems and procedures designed to avoid or minimize the impact of mistakes. Systemic methods for patient safety have been called for many times, but individual accountability for errors persists, indicating how entrenched this thinking is in health care. Regarding systems engineering and human aspects, the work style, perspective, and pace might conflict with the quick healthcare improvement initiatives.

Communication in the healthcare context is a very dynamic and complicated process. Including new problems, participants, and venues present another chance to improve patient safety (Ross, 2018). To provide safe patient care, good perioperative communication is essential. It is also a crucial component of effective team collaboration. Communication must be precise in an environment where many obstacles and problems exist, making the task much more difficult. Surgical checklists and time-out procedures have contributed to a uniform, inclusive approach to tackling communication issues in the perioperative setting. These issues can be addressed by postoperative debriefing sessions, which have proven successful in the virtual educational setting.

Patient safety may be improved through systems engineering and human factors, particularly in preventing surgical errors. They cover a wide range of patient safety sectors and have made significant contributions to the design and implementation of technology and procedures in the workplace. All the healthcare facilities must adhere to the National patient safety goals and ensure the patients are safe within the facilities.

 

 

References

Carayon, P., Wooldridge, A., Hose, B. Z., Salwei, M., & Benneyan, J. (2018). Challenges and opportunities for improving patient safety through human factors and systems engineering. Health Affairs, 37(11), 1862-1869. https://doi.org/10.1377/hlthaff.2018.0723 (Links to an external site.) 

Ross, J. (2018). Effective communication improves patient safety. Journal of PeriAnesthesia Nursing, 33(2), 223-225. DOI: https://doi.org/10.1016/j.jopan.2018.01.003 (Links to an external site.) 

World Health Organization. (2018). Patient safety: making health care safer (No. WHO/HIS/SDS/2018.11). World Health Organization. https://apps.who.int/iris/handle/10665/255507 (Links to an external site.)