Question

Describe an evidence based practice or quality improvement intervention for medical errors.

Answer 1

Ans) Given the history of error reporting and the role nurses have in patient care, it is important to emphasize that nurses are pivotal in improving patient safety via error reporting.

- Patient safety will improve when systems effectively assure and improve safety, predicated on a culture in which the reporting of errors or near misses is considered valuable, and positive actions lead to study and change for improvement, not blame.

- To avert underreporting of errors and to effectively learn from errors, administrators in health care agencies need to develop policies that support the routine reporting of errors, so that increased numbers of reports of actual errors and near misses are rewarded on an individual or unit basis.

- By easing the transition of an institution to a culture of safety, eliminating blame and the pressure of a punitive environment, error reporting will most likely increase. Additionally, it is evident that caregivers and patients profit from detailed accounts and increased reports, specifically in hospitals that act on unsafe practices identified through analysis of error reports.

- Systems improvements need to be communicated with all stakeholders so that they benefit from seeing the feedback loop in action.

- Ethical principles—including beneficence, fiduciary responsibility, respect for autonomy, justice, and honesty—guide clinical practice and mandate reporting and disclosure.156 These principles guide safety efforts and must be espoused by administrators and providers. Improved safety practices begin with policy and procedure development and continue with the allocation of resources for developing reporting systems and databases as well as educating caregivers.

- New systems of reporting errors are generally developed in-house or purchased by health care agencies. Electronic systems that are Web-based—that include easy reporting and standard definitions of errors, near misses, and potential root causes as well as personnel responsible for analyzing and sharing safety hazards—provide opportunities for data management and pattern identification of unsafe practices.

- They also save time for providers as reports are entered into databases and help to shorten the time from incident to report. Developing new systems of reporting requires administrators to budget accordingly so that additional personnel and electronic reporting systems as well as complementary software are financed.

- Periodic training of personnel and upgrading reporting databases are necessary, as are systems improvements that depend on error-report analysis.

- Patients and families desire disclosure of health care errors by health care providers. Providers have an ethical responsibility to disclose. Generally, organizations use verbal reports, followed by written reports offered by patient safety officers, in consultation with agency attorneys, in accord with institutional reporting and disclosure policies. Refusing to disclose suggests fear and a need for provider control rather than patients’ and families’ need for honesty about their care. Disclosure policies must be created with honesty and respect for patient autonomy in mind; apologies must be required.

- The emotional responses and perceptions of caregivers about errors are important barriers to reporting. Providers consider themselves at risk when they report errors because many providers carry the residue from previous experiences with mistakes. Anger from coworkers, shame, lack of confidence, and the like combine with guilt about the suffering of patients and fear of potential litigation to hinder reporting and disclosure. Nurses respond similarly to errors as physicians. They feel vulnerable to disciplinary action and legal repercussions; thus errors go underreported. Providers must experience changes in institutional culture, where systems improvements are targeted rather than individual blame.

- Teamwork training improves error reporting and reduces clinical errors. Teamwork principles include increased communication among health care providers. One element of a teamwork training program, cross-monitoring, might result in decreased errors as providers observe each other, identify unsafe behaviors, and act to correct each others’ mistakes. Status barriers must be penetrated. Cross-monitoring involves interdisciplinary/caregiver observations, identifying unsafe behaviors, and acting to correct unsafe behaviors. The challenge is how this team training element might be successfully initiated and consistently reinforced in acute care hospitals, critical access hospitals, nursing homes, long-term care facilities, and other agencies. Along these lines, nurse educators are challenged to include teamwork strategies and exercises aimed at increasing safety practices in health care agencies in undergraduate and graduate nursing courses, taking into account content on existing status issues among health care providers.