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The twentieth-century medical sector has been criticized for the lack of a stable patient’s safety policy and inabilities to create the systems under which healthcare is properly provided. Insurance companies have to take responsibility for any errors that occur in the healthcare system, still, these companies do not find it necessary to elaborate on the challenges even because its vast majority aims are reducing patients’ claims and necessities.
Every day numerous preventable events occur in the medical field that could be easily avoided in case proper regulation and enforcement of patient safety are considered. The point is even though some regulations are provided, not enough information is used to prove the idea that these regulations may considerably improve patient safety.1 Several attempts made by media reports as well as the various interested parties such as insurance companies have resulted in the formulation of a range of policy proposals that aim at providing an amicable solution to the question of patient safety.
The complexity and bureaucracy that comes with medical systems take up the greater share of the blame, and healthcare systems choose to allow the various organizations to device their mechanisms of dealing with the problem. The purpose of this paper is to prove that several alternatives may be used to elaborate medical errors, promote the improvement of medical healthcare under a variety of conditions, and stop blaming individuals for making mistakes that are not always based on personal poor knowledge or experience.
The current statistical data in the US indicates that tens of thousands of American people die annually because of preventable medical errors.2 This fact falls in the range of other causes of death such as road accidents and breast cancer. Still, the statistics omit some unreported deaths caused by medical harms as well as those which are reported as serious still not as fatal.3
It is common knowledge that the healthcare sector has remained a step behind the trend in all other sectors in as far as industrial safety is concerned. Several investigations have been conducted to define the connection that takes place between the already existing systems and the number of errors that lead to unpleasant results in medical practice. The researchers such as Runciman and his team, Watcher, and Vincent introduce different points of view and develop their ideas on the fact that it is wrong to blame one person in case of incompetence or negligent performance.
The distinction of Errors and Adverse Events
There is a need to distinguish between errors and adverse events. It is possible to admit that the error differs from the adverse event by the fact that the error occurs by an act or omission whose consequences are the undesired outcome.4 And the injuries which are usually caused by medical management or misacts are usually defined as adverse events.5
According to Wachter, some people may argue that there is no difference between medical errors and adverse events since the parties end up suffering in either case. However, this argument lacks weight since the distinction between these terms helps us in identifying the party on whom the burden is to be placed.6 The prevention and management of these events require the engagement of better scientific methods that do more than reform how things are done. The reform of these systems and procedures will be motivated to a great extent by the ethical and professional considerations and standards. It would be an empty attempt to administer a policy that is directed to prevent the errors and be ready to take the actions which are safe for patients as well as for the medical staff.
Vincent offers a captivating and rather effective policy in his research that is based on record reviews. What is offered is the definition of several stages that have to be taken by nurses. The first sage is all about the identification of the records which may be helpful in the investigations. Watcher also attempts to gather and evaluate different medical errors to educate the staff and help doctors define their activities. The next stage should encourage doctors to analyze the records and learn about the mistakes and misunderstandings dated earlier.
Finally, it is not always required to compare the current challenges with those which came from the past. This is why even Runciman and his team of researchers admit that the classification of the adverse events will help to improve considerably medical treatment and correspondence to all ethical and professional standards which are required.7
Technological and ideological advancement in the 20th century has played a tremendous role in motivating the study of medical error and patient harm. Historically, the problem has been neglected and given little if any attention.8 This outlook has changed especially in the last ten years that have seen the medical error debate take a political twist into the professional and public arena. Oblivious to the fact that there were millions of people suffering under the harm of medical errors the medical institution continued to ignore this aspect.
Accountability and Policy
Unfortunately, the focus has been on medical errors rather than the methods or the system that may reduce such events. Furthermore, Runciman claims that the focus sometimes was on blaming the individual as the error was considered to be a moral failure,9 which left both the physician and the patient feeling accountable and unsafe. Thus, in general, anyone working in a system that has not set safety as one of its major priorities may fall under the medical error and be blamed.
Traditionally the burden of medical errors was placed on physicians and nurses since they were the actual people on the ground involved with the treatment care and operation of the patients; however, their cooperation with the representatives of management department is not as successful as it might be, this is several misunderstandings and errors take place.10
In a general sense, accountability may push many nurses and physicians to the assumption of responsibility for actions and omissions committed.11 After an error takes place, it is necessary not only to take responsibility but also be able to inform the patient and family, apologize, and explain what actions may be taken to prevent some problems in the nearest future.12 The author argues that physicians are prone to trouble regardless of their education and training. Thus, the focus should move from blaming an individual toward patient safety.13
For instance, the early 1960s physician was supposed to master at least 15 different medications that were necessary for the treatment of common illnesses of the time. Still, such an attempt cannot be properly justified as this individual error did take place, and even sufficient education and training were not enough to overcome the error and make use of the knowledge gained. This is why it is hard to define the quality medical backgrounds in case some errors take place.
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The medical practice has since grown to thanks to technology and research. As a result, there has been also an increase in the number of medication errors that have risen to over 12% of the whole reports.14 It would, therefore, be unreasonable to imagine that the modern-day physician will be able to memorize and utilize that information when required. The advancement has brought about new challenges as well as increased risk of medical errors.
The justification for the adoption of these technologies has been that there is a better chance that the machines will make fewer errors compared to humans.15 It is the probability of error in a human being; this is why it is much more relative than that of the machines. Machines are not able to take care of the environment or to promote the required safety to patients, and it is to decide whether such participation of the machines may be justified.
Even so, the thought of an entirely safe environment for the treatment of patients is a farfetched fallacy,16 since there are many other variables involved in the treatment process. In general, the machines cannot function without individual management and therefore the chances of a slip or miscalculation still do exist.17 Consequently, a machine will keep on with its function regardless of the surrounding effect, while a human will see what is going on and will base on that they will modify their actions.
The advancement in technology offers a conveniently delicate chance for hedging against and prevention of medical errors. Machines require due diligence and care since a simple slip could cause grievous harm or even death. Therefore, it means that the human element should be carefully examined in the formulation and adjustment of the system of error management. Several policies may be implemented in the system to control the outcomes which are not always easy to predict under some particular conditions.
First of all, it is very important to report any medical errors and work on avoiding similar future mistakes that may affect the safety of the patient or weaken the organization’s performance and reputation. And second, it is beneficial to promote a policy using which management of errors will be easier and will correspond to standards set by society. The example of a successful policy is introduced by Vincent. He discusses the achievements of Jeffrey Cooper with the help of whose achievements the work of anesthetic machines has been considerably improved.
Through thorough observations, the researcher proved that several adverse events and errors may be controlled in case more attention is paid to the way of how the operation is managed each time.18 Such a policy helps to regulate the behavior and sets standards that should be met by the practitioners as it will create a benchmark for the medical practice upon which records of compliance may be taken.
It also allows for the creation of an oversight body that regulates and controls the activities of the different participants, this is why the author justifies it from a variety of aspects. Another powerful contribution offered by Wachter is the justification of the Human Factors Engineering (HFE) as one of the techniques that can be used to improve the system performance and reduce errors.19 This model emphasizes the device design and the use of it such as catheters, computers, etc.
Approaches to Minimize Errors
The last ten years have conclusively altered the traditional approach from the individualized approach that seeks to place the blame on the individual to an ethical campaign that seeks to ensure that people are more careful. The change has been motivated by two main aspects. First, the traditional approach ignores the fact that the errors are committed by hardworking and well-trained individuals who have been tried and tested for the performance of these activities.
It, therefore, acted to discourage the practitioners and limit the exploratory ability of the participants in the field of medicine. Secondly, the medical field is inadvertently a victim of the inevitable human error. It is within human scope to make mistakes and the medical field is of no exception; unfortunately, the mistakes made in this field are much more crucial for human lives in comparison to the mistakes made in other fields. The extent of safety is no longer a matter of individual care but more of the ability of a system to predict and manage an error.20 This proactive approach had been successfully implemented in other industrial sectors such as the nuclear and aviation sectors.
It also embodied an investigation and analysis of the trend presented by dozens of accidents in non-healthcare fields such as aerospace and transport fields. The prevention model helps to define the conditions under which an organization with a complex system of management sets its requirements and the participants of the system such as doctors and nurses have to evaluate the occurrence of errors by themselves.21 Before the occurrence of these errors, a person has to penetrate a host of system checks that regulate chances of occurrence of a tragedy or error. 22
In effect, the model suggests that it is not a question of perfecting the human act but more of the reduction of an opportunity for the engagement on the human in risky behavior. Sometimes, it seems to be enough to identify possible errors and try to do everything to avoid the problems. Still, even professional medical staff is not always ready to make use of their experience and achieve the best results. This is why the offered model concerning the prevention of errors may be integrated into a variety of ways considering the requirements set by a particular case.
One of the most common ways to minimize errors that have been conducted worldwide is the “double checks”; to ensure that some procedures are performed correctly, such as blood administration; it has to be double-checked by nurses before transfusion takes place. And now the majority of hospitals are using these techniques for other high-risk medication. The regulations, accreditation standards and laws have an important role in ensuring patient safety, as they make obligatory following the right instrument on the right job. They are powerful tools to promote patient safety in that they can mandate certain practices.
For instance, in the case of the pilot who landed successfully on the Hudson River, when he was asked how he did it, he replied: “I put my hand on the side stick and I said, the protocol for the transfer of control, my aircraft, and the first officer answered your aircraft”. The meaning here is that having a strong protocol and standards for patient safety will help in rescuing the patients and the providers from falling into such medical errors.
Response toward Medical Errors and Patient Safety
In response to the concerns of errors and patient safety, Wachter suggests utilizing the “Swiss Cheese Model” to analyze the errors and minimize it.23 In some events, this model has been proved to help on locating the source and the cause of the error and make it foreseeable. Thus, from that point, providers can implement multiple courses of protection to diminish the cause of such errors. For example, respect and assure meeting patients’ preference regarding resuscitation, or guaranteeing that the operation will be done on the correct limbs.
In contrast, on Safety and Ethics in Healthcare, Runciman argues on the efficiency of applying the “Swiss Cheese Model” with some hospital departments. For example, using the multiple tests and verifications to ensure that the patient has received the right medication and eliminate the infection of the wrong medication might be practical in some departments, and might not be for other departments such as the emergency department. Because of the higher demand and the time consuming, the patient might die from an infection while the providers are still navigating steps.24
Another side effect is that busy physicians and nurses might disregard the required steps to focus on their patients.25 However, the “Swiss Cheese Model” might be practical at the beginning of the discussion and eventually become unworkable on when to render the clinical service. The peculiar feature of the chosen model is the possibility to control the errors and do not provide them with a chance to spread into the system. The author perfectly compares it with the holes in the cheese. It is hard to find a slice with the holes which are at the same place. The same happens with the errors. They do not happen at one place several times, this is why the medical staff has to be ready to identify the error, try to prevent it if possible, and evaluate its effects on patient safety and care.
The perplexity embraces the continued lack of a comprehensive ethically motivated mechanism for the management of and the improvement of the safety conditions in the healthcare system. Even though there is a great deal of information that has been documented regarding the role of systems in the increased number of medical errors, policymakers are not keen to confront the problem as it is. The point is that medical errors are usually inevitable; they are inherent to the system, this is why it is not always rational to fight against them.
Of course, the easiest way is to blame a person and make his/her take responsibility for the errors. Still, the healthcare system has to be based on properly chosen strategies and ideas, this is why it is better to focus on different models like the Swiss Cheese Model or any other defined in the paper. Though one of the main principles in healthcare is to not harm patients, several debates still take place. The principle of non-malfeasance stretches the obligatory net to accommodate errors of commission such as incorrect drug prescriptions, careless surgical slips, administration of drugs to the wrong patient and misstatements in the entry of records.
Even though the errors that occur can be limned to the individual in person the professionalism concept of ethics indicates that the patient is the primary object of safety. Safety from an ethical point may also be justified by the utility concept. The utility principle recommends maximum benefit for the greatest number of people. The public policy aims at ensuring the general safety of the public. Public health ethics demand that the policies adopted should in as far as possible execute safety improvements. Therefore, it is more effective to identify errors and implement systems that prevent care providers from committing such errors instead of searching for a person to be blamed.
Runciman, Bill, Merry, Alan, Walton, Merrilyn. Safety and Ethics in Healthcare. Hampshire: Ashgate, 2007.
Vincent, Charles. Patient Safety, West Sussex: Willey-Blackwell, 2010.
Wachter, Robert, M. Understanding Patient Safety. New York: McGraw-Hill Companies, 2008.
- Wachter, Robert, M, Understanding Patients Safety (New York: McGraw-Hill Companies, 2008), 183.
- Wachter, xviii.
- Runciman, Bill, Merry, Alan, Walton, Merrilyn, Safety, and Ethics in Healthcare, (Hampshire: Ashgate, 2007), 2.
- Wachter, 4.
- Vincent, Charles, Patient Safety, (West Sussex: Willey-Blackwell, 2010), 52.
- Vincent, 53.
- Runciman et al., 39.
- Runciman et al., 95.
- Runciman et al., 93.
- Vincent, 359.
- Runciman et al., 97.
- Wachter, 232.
- Wachter, 211.
- Runciman et al., 46.
- Runciman et al, 95.
- Runciman et al, 126.
- Wachter, 22.
- Vincent, 21.
- Wachter, 22.
- Runciman et al, 229.
- Vincent, 77
- Runciman et al, 111.
- Runciman et al., 12.
- Runciman et al., 4.