Attitudinal Barriers
1. Being arrogant and proud
2. Placing self-interests before patient-interests
3. Perpetuating perfectionism; blaming and humiliating those involved with errors
4. Perpetuating silence about errors, denying errors, or believing others don’t need to know about one’s errors
5. Allowing competition with peers to inhibit disclosure
6. Believing disclosure is an optional act of heroism
Self-recognition of specific attitudes is the first step to overcoming them as barriers. Physicians should closely examine their attitudes towards full disclosure of medical errors to determine if these specific “attitudinal barriers” are present. Attitudes may be more difficult to manage or change than other barriers identified. Professional assistance may be required to overcome attitudinal barriers.
Concerns over lack of control
1. Being uncertain about how to disclose
2. Disagreeing with a supervisor or trainee about whether an error occurred
3. Being uncertain about which errors should be disclosed
4. Being uncertain about the cause of the adverse event
Barriers listed as “uncertainties” generally involve a lack of knowledge, the need for disclosure education and/or further investigation of the incident. These barriers can be overcome fairly easily by first recognizing the barrier, seeking the knowledge or education that is lacking and/or by continuing to investigate the facts and circumstances surrounding the error.
Fear and anxiety of lack of time to disclose errors
1. Fearing legal or financial liability
2. Fearing of professional discipline, loss of reputation, loss of position, or loss of advancement
3. Fearing the possibility of “fallout” on colleagues
4. Feeling a sense of personal failure, loss of self-esteem,...
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...g unanticipated events with the patient and families. We have found this gives both the patients and staff comfort knowing the hospital is aware the incident has occurred and we are working as a team on a process to stop it from happening again.
5. Timely – The incidents are viewed, analyzed and reported back in a timely manner to avoid further risk to the patient or staff. During shift change each unit has a Safety Huddle to discuss and safety concerns on the unit. Every day each department/unit reports to administration for Safety Huddle to discuss all the hospitals incidents from the previous day. We use this time as an open forum not to point blame, but to learn from others experiences and to come together to help solve issues.
6. Reports – The final report focuses on the hospital system or department as a whole instead of the individuals that were involved.
The final report, published in 2013, is what has come to be known as The Francis Report. The Francis Report has become a driving force to promote change, lead, shape, fund and improve all aspects of health care, and make sure that people receive the support, care and treatment they require, with the compassion, respect and dignity that they deserve.
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
With patient safety always being the number one priority FTR is the worst case scenario for the hospitalized patient. In an article titled “Failure to Rescue: The Nurse’s Impact” from the Medsurg Nursing Journal author Garvey explains ways FTR can occur “including organizational failure, provider lack of knowledge and failure to realize clinical injury, lack of supervision, and failure to get advice.” Nurses are problem solvers by nature, they heal the sick and help save lives. FTR is a tragic experience for everyone involved. The recent surge in this happening across the country has given FTR cases widespread media coverage. Hospitals are trying to figure out what the root cause is and how they can be prevented. Fortunately, with the advancement of technology and extensive research many hospitals have developed action plans and procedures to help prevent the early warning signs from being
Medical error occurs more than most people realize and when a doctor is found negligent the patient has the right to sue for compensation of their losses. Debates and issues arise when malpractice lawsuits are claimed. If a patient is filing for a medical malpractice case, the l...
ways, such as not having DNA evidence, not enough information about the crime, and lastly
Truth in medicine is a big discussion among many medical professionals about how doctors handle the truth. Truth to a patient can be presented in many ways and different doctors have different ways of handling it. Many often believe that patient’s being fully aware of their health; such as a bad diagnosis, could lead to depression compared to not knowing the diagnosis. In today’s society doctor’s are expected to deliver patient’s the whole truth in order for patients to actively make their own health decisions. Shelly K. Schwartz discusses the truth in her essay, Is It Ever Ok to Lie to Patients?. Schwartz argument is that patients should be told the truth about their health and presented and addressed in a way most comfortable to the patient.
Furthermore, there should be enough trust between the nurses and physicians where they can easily put aside their egos and ask for a second opinion when they have any doubts concerning a patient's safety. This was clearly exemplified when the nursing staff attending to Lewis Blackman failed to contact the physician when various side effects arose; instead they tailored the signs to fit the expected side effects. Even after Blackman’s health was deteriorating, the nurses remained in their “tribes” and never once broke out of it to ask for help. The entire hospital was built on strong culture of remaining in their tribes instead of having goals oriented towards patients care and safety.
To start off, the article’s introduction states that one of the leading causes of medical error and patient harm is due to ineffective communication of health care professionals. Specifically the article states, “A review of reports from the Joint Commission reveals that communication failures were implicated at the root of over 70% of sentinel events.”(Dingley, 2008). So basically, 70% of circumstances
In the United States, hospitals and organizations find ways to help prevent events that should rarely or never occur, often called Never Events. The list of Never Events is made in order to provide hospitals with incentives to make sure the occurrences of them are reduced. As Mrs. Friend states, “If revenue decreases in our health care facilities because of “Never events” this could impact nursing in many ways. The rate of pay, staff to patient ration, availability of modern medical equipment, and our health insurance premiums will all be affected” (Friend, 2009, p. 5). One major type of Never Event that happens more often than it should is a surgical never event. Although, the occurrences of surgical Never Events may not be out of control, we must take into account that they are only reported if they are discovered. In today’s society the occurrence of Never Events should be virtually zero because of the technology available to prevent them.
Failure to communicate information that affects care (e.g., inadequate or inaccurate documentation, as well as not contacting a physician with pertinent patient information when applicable).
Wu, A. W. (2011). The value of close calls in improving patient safety: Learning how to avoid
...nt an organizational chart. This allows all personnel to understand what their roles are at time of incident, and whom you communicate sensitive information too. If no direction or communication is given, providing facilities run the risk of victims trying to enter their doors seeking care, which can over exhaust resources and oversaturate hospitals. Therefore, a hospital triage is implemented to assess if patient condition has worsened or remained stable, if there is a need for decontamination process, or if a person seeking assistance is a family member looking for victim. Having these procedures ensures that patients inside the hospital prior to incident are protected for potential harmful exposure to contamination agents and other measures. In addition, hospital and providing facilities are a source of information for victims, the media, and family members.
As medicine becomes more commercialized, patient-physician relationships become less intimate and thus patients hold less sympathy for doctors who make mistakes. Having no emotional ties to their physician, patients are more likely to change doctors after they discover their current one has made a mistake. This is a problem for physicians as it is a loss for their business and ultimately their revenue. Because physicians want to keep a steady influx of patients and avoid malpractice they have equated mistakes to loss of business. “It’s almost impossible for a physician to talk to a patient honestly about mistakes because of the doctors fear they will lose patients” (Gawande 58) But, a 2006 study in the Journal of General Internal Medicine found full disclosure of error reduces likelihood that patients will change physician and improves satisfaction, increases trust, and results in a generally positive response from the patient. By fully explaining why the error occurred and how the patient should have been treated, the doctor takes responsibility for the error, which many patients respect and appreciate. This appreciation can go a long way in the patient-physician relationship and in most cases, help the patient forgive his
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
In today’s health care system, “quality” and “safety” are one in the same when it comes to patient care. As Florence Nightingale described our profession long ago, it takes work and vigilance to ensure we are doing the best we can to care for our patients. (Mitchell, 2008)