Objectives, Strategies, and Background
Notwithstanding the quality of health care in developed countries, the influence of the human factor remains substantial. Notably, Al Mutair et al. (2021), with reference to The National Coordinating Council for Medication Error Reporting and Prevention, describe malpractice as “the sixth cause of mortality in the United States” (p. 47). The mistakes frequently originate from the inappropriate organization of everyday activities in medical facilities. A closer focus on working conditions, especially those of nursing staff, therefore, would reduce the probability of unwanted occasions. Other points to consider are the awareness of the personnel and the quality of communication among them, as the lack of both may cause misunderstandings, hence improper actions. The purpose of the paper lies in investigating the causes of medical errors and, subsequently, designing a strategy or strategies for minimizing those.
Objectives
The main goal of the project is to decrease the number of mistakes that the personnel of the medical facility under review make by two times during six months. The steps towards that, which actually form the list of objectives, are as follows. Primarily to develop a typology of malpractice by its nature as well as consequences and apply it to the case. The next stage is analyzing the causes, which requires a thorough examination of the workplace, the working schedule of the staff, their knowledge, and the intensity of interaction among them. The outcomes will reveal the existing drawbacks and, consequently, set the direction or directions for building the “culture of patient safety” at the facility (American Society of Health-System Pharmacists, 2018, p. 1493). The successful implementation of the latter, in turn, is the key to reducing malpractice.
Strategies
Medical errors are possible to classify by two main criteria, specifically, the event that happens and the severity of the consequences. The basic categories of the former are omission or an action that has not been taken and commission or wrong action (Rodziewicz et al., 2021). In terms of harm to the patient, malpractice can be minor and causes temporary inconvenience but bears no life-threatening or serious, whose consequences are irreversible and sometimes fatal (Bari et al., 2016). In addition, a mistake may be active or latent, depending on whether the outcomes become apparent immediately or with time (Rodziewicz et al., 2021). Considering the underreporting that results from the fear of punishment, it is difficult to estimate which typically occurs more frequently in fact.
As said above, a considerable share of mistakes, regardless of their type, root in poor work organization. This umbrella term comprises long hours and overload that affect attentiveness as well as the speed of reaction, a lack of staff lounges, and even insufficient lightning that causes incorrect prescription readings (Bari et al., 2016). Therefore, the cornerstone of patient safety is the comfort of the personnel, which, consequently, has to be a priority for hospital administrations. Simply stated, hiring more nurses doubtlessly is a more appropriate solution than waging the existing for extra work, as the latter leads to incomparably more substantial losses. Neither is it acceptable to save on lamps since the outcomes may be tragic.
The incompetence of staff is another source of medical errors that, in turn, derives from improper training or its complete absence. Thus, 40% and 52%, respectively, of medical practitioners report the lack of knowledge and experience as the main cause of the mistakes that they have made (Bari et al., 2016, p. 525). Less common but similar reasons are the complexity of the case and an inadequate presentation that embarrass semi-skilled personnel. The statistics illustrate the criticality of permanent in-house education that should target updating the knowledge of both doctors and nurses so that it corresponds to the recent findings of medical science. A reconsideration of staffing policy may also be relevant to eliminate hiring individuals without core diplomas.
Finally, medical errors are a common consequence of faulty communication, especially between professionals at different levels. That, in particular, includes not asking for advice “from senior” as well as “inadequate supervision” (Bari et al., 2016, p. 525). The scarcity of interaction, in turn, may result from that of time; simply stated, staff frequently are too busy to consult their junior fellows or newcomers. Besides, some professionals disregard less experienced colleagues because of their belief in their own superiority. Therefore, promoting mutual respect in the team is worth mentioning among the factors of improving patient safety.
Background
The personnel of the hospital under review report minor medical errors, both of omission and of the commission, ten times a week, on average. The most typical among those are latent, such as inappropriately long intervals between drug administrations and bruising after injections. This amount is to be decreased twice in half a year, which requires the identification of the causes as the primary step. The analysis has shown that the configuration of the workplace is quite proper in terms of comfort, and the staff members stay in contact permanently, which two points doubtlessly are the advantages. However, there is an apparent scarcity of nurses, and not less than one-third of those present are in their first post-graduation year.
As the practitioners are few, each of them has more duties, in fact, than he or she would do otherwise. Meanwhile, having “many other things to take care of” is the third most frequent cause of mistakes (Bari et al., 2016, p. 525). Even experienced nurses are not necessarily able to bear large masses of information in memory and be maximally careful during procedures when the intervals between those are excessively short. The stress resistance of most young professionals is lower by definition and, furthermore, decreases with the growth of work intensity. Therefore, they are more likely to forget to administer a medication to a patient or hurry while injecting, which results in bruises.
The problem has two solutions that are possible to realize within six months. First, it would be reasonable to hire a certain amount of people with appropriate nursing experience to outbalance the newcomers. This variant, however, presupposes additional investments in waging; hence is acceptable solely if affordable. If the facility does not have sufficient finance, its administration could implement mandatory in-house training in the form of experience exchange. Simply stated, those who have done nursing for years could help their younger colleagues acquire and/or boost important non-medical skills, such as concentration.
Conclusion
The three most common causes of medical errors are overworking, lack of competence and poor communication. Resulting from those, practitioners may skip necessary actions by accident or do them in the wrong way (Rodziewicz et al., 2021). Therefore, it is critical to organize both the workplace and the schedule properly, which means comfortable conditions and adequate load. Training is of great importance as well since it refreshes and enhances the knowledge of personnel, hence maintaining it up-to-date. Finally, staff members have to communicate on a constant basis to avoid misunderstanding, which is also essential for patient safety.
References
Al Mutair, A., Alhumaid, S., Shamsan, A., Zia Zaidi, A. R., Al Mohaini, M., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46-58.
American Society of Health-System Pharmacists. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75, 1493–1517.
Bari, A., Khan, R. A., & Rathore, A. W. (2016). Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan Journal of Medical Sciences, 32(3), 523-528.
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. In StatPearls.