1.1 Background
In high hazard industries, errors and accidents may lead to terrible outcomes. Patient safety is an important public health issue worldwide. According to the World Health Organization (WHO), a person on an airplane has 1 in 1,000,000 chances of being harmed, whereas, a patient has a 1 in 300 chances of being harmed in a healthcare facility. A hospitalized patient has a 14% chance of developing an infection, which may be prevented with an extra precaution and appropriate hygiene. In addition, 50% of complications that occur during surgery may be avoided (1). In 2016, a study by Makary MA and Daniel M reported that medical errors are the third leading cause of death in the United States (US), following heart diseases and cancer
…show more content…
The term error can be further classified to active and latent errors, sharp end – and blunt end-errors, and lastly slips and mistakes (3). Active errors occur between a person and part of a system that result in an immediate effect on health and safety. Unlike active errors, latent errors occur due to failures in health and safety management systems, organization or design and they are easily missed and may remain unnoticed for days, weeks, or months until they result to an accident (4). Errors at the sharp end relates to elements or people in the healthcare system that are in a direct contact with the patients. Whereas errors blunt ends do not occur in direct contact with patients but influence the personnel and devices at the sharp end that do. Slips are errors that occur because of sensory or emotional distractions, fatigue, and stress, while mistakes are due to lack of knowledge or misunderstanding. Another common term in healthcare is a near miss event, which is “an event that did not result in an injury, illness, or harm, but had the potential to do so” …show more content…
By the end of the 1990s, many and well documented reports of poor patient care, in correlation with well-publicized informal reports of medical errors, raised the public's attention about the quality of healthcare (8). The Institute of Medicine (IOM) responded by forming a Quality of Healthcare Committee to develop ways to improve the overall quality of patient care in the US. The committee's publication on patient safety, “To Err is Human”, had an important role in focusing the nation's concerns on this topic (9). By that time, the goal was to form an environment in which culture of safety is the main priority in any healthcare organization (10). Their recommendation was to improve systems by learning from failures instead of blaming individuals, to enforce mandatory or voluntary reporting systems, and to develop strong leaderships (11). One of the most widely used definitions of the term safety culture was developed by United Kingdom (UK) Health and Safety Commission, which was “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management” (12). Throughout
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
Introduction The Patient Safety Plan is a program that provides a systematic, coordinated and continuous methodology to the upkeep and upgrading of safety through the founding of mechanisms that support effective responses to definite incidences in an organization work environment. It is also the incorporation of patient safety main concern into new strategy in an organizational functions and services which would lead to continuous positive decrease of risk in the work environment. Patient safety plan is used as a guide to approach optimum safety objectives which involves different departments and disciplines in creating plans, processes and devices that contain the patient care safety activities in a hospital setting (Main Line Health Inc,
Kohn, L., Corrigan, J., & Donaldson, M. (1999). To err is human: building a safer health system. Committee on Quality of Health Care in America Institute of Medicine National Academy Press Washington, D.C.
Today, medical error has become a major and important challenge to health care systems across the globe. This is because medical errors often lead to harm that may also be non-repairable (Valiani et al. 540; Denham “Chasing Zero”). In 1999, the Institute of Medicine published a report that indicated that medical error in hospitals accounts for between 48,000 and 98,000 deaths annually (Swift et al. 78; Barger et al. 2441). As such, reducing the occurrence of medical errors has become an international concern. Poorolajal defines a medical error as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.” (Poorolajal, et al. para 5 -10). In this case, it’s very important to acknowledge
Many hospitals have systems of checks and balances to avoid errors, but what happens when the systems do not work? Today in the United States, medical errors are the fifth-leading cause of death. In 2000, the Institute of Medicine released a study, “To Err is Human”, revealing an estimated 98,000 deaths annually from medical errors. While this figure is assumed to be lower than the actual, each death comes with an inherent cost to the health care system. In today’s terms this figure is underestimated, however the accompanied cost is estimated to be between $17 billion and $29 billion annually.
Throughout history, beginning as early as 500 BC, animals have been used to test products that will later be utilized by humans (“Animal Testing” 4), what isn’t publicly discussed is the way it will leave the animals after the process is done. Many innocent rabbits, monkeys, mice, and even popular pets such as dogs are harmed during the testing application of cosmetics, medicine, perfumes, and many other consumer products (Donaldson 2). Nevertheless, there are many people whom support the scandal because "it is a legal requirement to carry out animal testing to ensure they are safe and effective” for human benefit (Drayson). The overall question here is should it even be an authorized form of experimentation in the United States, or anywhere else? The fact of the matter is that there are alternatives to remove animals out of the equation for good (“Alternatives” 1). They are cheaper, and less invasive than the maltreatment of the 26 million innocent animals that are subjected to the heartlessness of testing each year (“Animal Testing” 4). All in all, due to the harsh effects of animal testing, it should be treated as animal cruelty in today’s society.
Behaviors to Improve Patient Safety. There are five behaviors in which I, as a health care professional, can practice in order to improve safety for patients in my direct care. These include following written safety protocols, speak up when you have concerns, communicate clearly, don’t let yourself get careless, and take care of yourself. By adhering to simple, basic protocols such as hand washing you can be a key player in reducing the spread of infection to your patients and thus, keeping your patients safe. As a healthcare professional you must be an advocate for your patients and their safety by reporting unsafe working conditions, close calls, and adverse events.
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
Patient safety incident reporting is a valuable source of information for providers, patients, and policymakers. It promotes accountability, learning, and improvement of patient safety culture. Patient safety is the pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes. It is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient . It is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information .
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).
“Leaders are essential to developing a safety environment, but all healthcare staff are responsible to practice safety” (Paradiso,2018). In a hospital setting there are many things that could go wrong if the healthcare workers are not vigilant or continuously double checking for any possible errors. Errors can happen in many places of the hospital, and it ranges from medication errors, surgical errors, contamination errors, falls, ulcers, etc. These are events that should never happen, but due to human errors and other causes we have an increased number of hospital “Never Events”. Never events are list of serious medical errors and adverse effects that should never happen to a patient in the hospital.
Medical mishaps occur more often than people may believe. According to John Bonifield from CNN, Medical errors kill more than 250,000 people in the United States yearly. Due to this large number of deaths relating to medical errors, hospitals and organizations are working together to lower the high number of mishaps. “Awareness about the problem has increased, but we clearly have to do more to get a lot closer to zero,” said Mark Chassin, President of the Joint Commission. The statistics of medical errors prove that mistakes are happening more often than they should. Often, individuals believe that these tragedies will not occur to him or her. Reviewing the statistics of various doctor rules and surgery reviews will help understand the level of seriousness our hospitals have reached. Through an understanding of the causes of medical errors, the frequency of medical mishaps will decrease.
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...
Patient safety as defined by World Health Organization (WHO) is simply the prevention of errors and poor effects to patients allied with health care (WHO 2015). Patient safety has, of course, been a serious global public health issue (Nieva & Sorra2003), as it is the same from the delivery of quality health care (Aspden et al. 2004). In the recent years numerous national initiatives have been implemented to improve patient safety and quality care (Victoria et al. 2013). Patient safety is the cornerstone of high-quality health care and is a common goal for all healthcare providers (Flanagan et al, 2004; Singh et al. 2005). Quality has always formed a central part of patient care, but quality management includes management of quality issues in all aspect of the organization (Sale 2005).