The research by Henneman (2017) aims to explore the nurse’s role in patient safety, including recovery of medical efforts and extraordinary actions for improvement of patient safety. The study found that the nurse’s role in the recovery of medical errors follows the near-miss model, thus stressing the importance of both organizational and human factors in preventing adverse patient outcomes.
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Henneman (2017) provides a detailed analysis of the role of nurses in the recovery of medical errors. The author argues that the Nursing Near-Miss Model can be used to explain medical errors; it defines technical failure, organizational failure, and human failure as the main sources of error in nursing. In turn, human failure can result from skill-based, rule-based, and knowledge-based behaviors (Henneman, 2017).
Thus, medical errors caused by human failure can result from lack of skills, knowledge, and appropriate procedures. The researcher argues that modeling medical errors aids in discovering reasons for failure and developing defense mechanisms. For example, Henneman (2017) found that strategies used by nurses to address errors included physical presence, review of the care plan, collaboration with another nurse or physician, and referencing practice standards.
Moreover, research suggested that bedside surveillance could help to avoid adverse patient outcomes if implemented during the defense or nursing recovery stages. However, the effectiveness of surveillance also depends on a number of factors, such as system, human, and environmental. The research also suggested that eye-tracking data could be used to “unravel the thought processes of nurses during routine yet error-prone processes” (Henneman, 2017, p. 276). For instance, eye-tracking data can help to determine sources of information used by nurses during surveillance (Henneman, 2017).
All in all, the study could be used as a guide for the use of surveillance in mediating medical errors, as it outlines the main system factors affecting the effectiveness of surveillance, such as resources, collaboration, patient and family involvement, and the use of existing technology (Henneman, 2017). Moreover, the research suggests new ways of avoiding errors during patient treatment, thus helping to enhance patient safety outcomes.
For example, Henneman (2017) suggests that eye-tracking data could help to prevent and mediate interruptions during error-prone processes, such as blood transfusion, whereas the use of eye-tracking as a debriefing strategy could improve safety practices. Overall, the study provides valuable insight into the factors that contribute to reducing and interrupting medical errors; thus, using the findings in practice allows enhancing patient safety and improving strategies for the recovery of medical errors.
Henneman, E. A. (2017). Recognizing the ordinary as extraordinary: Insight into the “way we work” to improve patient safety outcomes. American Journal of Critical Care, 26(4), 272-277.