Team: Executive Committee Presentation

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Medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. These tips tell what you can do to get safer care. When writing prescriptions they must be written legibly, clearly, and unambiguously. The patients weight must be confirmed. Instructions about how to administer the medication must to written out clearly. Abbrevations can not be used for dosage units or for the name of the medication. When a medication dose is less than one always use a zero to the left of the decimal to avoid fold dosing errors.

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Errors may suggest that there is not enough staff or that the system has some deficiencies. Staff may be tired and unable to make good judgments. This harried work environment may lead to less than quality care. Since the public expects that they will receive quality care. Whenever there is an error, the option of covering up raises serious ethical questions. Potentially, harm will occur to the patient and trust will be eroded because patients, families, and other health care providers do not know the truth.

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Every year The Joint Commission reviews health care organizations by a on site survey to conduct a evaluation of standards for compliance called Periodic Performance Review. This review focuses on helping organizations identify performance for areas of improvement as well as assisting in correcting these non- compliance areas before the next on site interview. Areas that are out of compliance with The Joint Commission standards requires for the organization to submit a Plan Of Action to the Joint Commission. The Joint Commission reviews each organizations Plan of Action. A telephone consultation is also scheduled. These consultations improve their plan of action without affecting the accreditation decision.

http://www.jointcommission.org/accrediation/resources for accredited organizations.aspx

Retrieved from www.jointcommission.org

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The first strategy critical to enhancing patient safety is to create a partnership with all stakeholders (Kumar and Subramanian 1998). Stakeholders in a healthcare organization include doctors, nurses, administrators, trustees, and patients, and by working together they tend to create ideas and generate effective solutions (Kumar and Subramanian 1998). Building a partnership with patients and families has also proven successful in improving all healthcare processes. Patient safety is a “team sport” that can only be achieved and sustained when all key stakeholders participate and contribute (Hudson 2004).The second strategy is to develop an effective system for reporting errors without placing blame (Leape 1994). Without a systematic method for identifying errors, patient safety is generally doomed to failure. Hospitals must develop a effective reporting system and it should be confidential, encourage reporting of errors, be unbiased, and ensure no justice for those reporting. Trust is a key factor to increasing the reporting of errors that has to be to establish within the organization. If incentives are offered medical errors will reduce tremendously. The third strategy is to promote open discussions about errors. The intent is to foster an environment where individuals feel comfortable with discussing errors and where information and knowledge are shared freely.

 

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The fourth strategy involves a cultural shift within an organization. A culture is a set of beliefs and values shared by members of the organization. Creating a safety culture in healthcare involves making patient safety the number one priority within the hospital and having the commitment as well as the ability to address patient safety issues. This means that the culture supports the idea that anyone can make mistakes. This strategy depends on shared values and norms of behavior expressed by top management and translated into effective work practices (Gaba et al. 2003). The fifth strategy is to provide staff with education and training in error-reduction techniques (Becher and Chassin 2001). Continuing medical education and training programs involve interventional risk management, which is an approach that can not only promote patient safety but also reduce malpractice lawsuits. Interdisciplinary training on patient safety has proven effective in strengthening healthcare teams and reducing errors.The sixth strategy is to conduct statistical analysis on collected data on errors (Becher and Chassin 2001). Simply collecting data is not sufficient it must be systematically analyzed to understand the sources causing medical errors. A common practice in hospitals today is training employees in the use of control chart analysis. This is important because research indicates that most errors stem from the interaction of several variables rather than from one underlying cause (Chassin and Becher 2002).The seventh strategy is to redesign the system of the process itself. System redesign refers to the implementation of changes in processes within a hospital and can result in improvements in overall quality of care (Leape 1994). The intent of this strategy is to reconstruct the system so that it is difficult or impossible to make a mistake. However, if a mistake does occur, employees are trained to correct it at the source.

 

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