Human Factors Impacting Health Care Settings - Essay Example

? Human Factors Impacting Health Care Settings Human Factors Impacting Health Care Settings Define and discuss human error theory The theory of human error is concerned with the processes that lead to errors rather than with the person who commits them (Reason, 1990). According to this theory, errors can be divided into three categories: violations, mistakes, and slips and lapses. The critical difference in these categories is that violations are deliberate errors while mistakes, slips and lapses are non-deliberate errors. It is important to note that both intentional and non-intentional errors are usually caused by different factors and are solved differently (Royal Pharmaceutical Society of Great Britain, 2005; Brand et al., 2008). Violations are committed when an individual fails to follow rules or guidelines despite being aware of them. For example, pharmacy attendants may be aware that it is prohibited to sell a certain type of medicine without the doctor’s prescription, yet they may decide to violate this rule and sell it to their customers without such prescription. Slips and lapses take place when, following a planned action, a person does something which should not take place according to the plan. For example, the plan of a pharmacist could be to prescribe drug A to the patient, but an error is committed when drug B is prescribed instead. The pharmacist could have committed such an error as a result of forgetfulness, which leads to the planned action being neglected (Institute of Medicine, 1999). When the desired goal is not achieved because the planned behavior is insufficient, then a mistake is said to have occurred. For example, a pharmacist can prescribe an antibiotic for the treatment of skin itch, whereas the signs result from a sexually acquired infection and not bacteria. All healthcare professionals and practitioners are human beings prone to making errors since no human being is perfect. In their daily lives, humans sometimes forget to do things or do them wrong. However, in healthcare settings, these mistakes can be hazardous and have catastrophic consequences. Undeniably, it happens very rarely that personnel go to work with the intention of hurting or harming patients. Sometimes, experience and awareness prevent such events from happening, because humans become over-cautious and vigilant when they face a situation which they know is risky. The theory of human error is increasingly gaining application in healthcare settings (Reason, 2000; Bogner, 1994). The theory recognizes that pharmacists are risk averse and safety-conscious, and this is very suitable in the investigation of non-prescription medicines consultation. Factors such as suboptimal communication are cited as some of the causes of violation in the context of health settings. For example, a pharmacist could be aware that customers are supposed to be served with some crucial information during the prescription of drugs, but they decide not to serve them with such information, which results in a failure to apply the ordinarily good rule. If such a violation is committed, it is important to find out the reasons why the pharmacists decide to withhold the information. Some of the external factors which can influence the pharmacists to withhold the information include pressure from customers and time constraints (Ovretveit et al., 2002). Synthesize and critically appraise the literature pertaining to common human factors impacting healthcare settings Different factors that influence people and their behavior have a great impact in health care settings. These include job, organizational and environmental factors as well as individual characteristics that impact on human behavior in health settings. Professionals in health care settings are daily engaged in treatment and care of patients. Essentially, the mission of these professionals is to provide high quality and safe health in the context of clinical care. However, occasionally their services exacerbate the patient’s symptoms because of factors that are described in the theory of human error. A shockingly high number of patients are injured in the course of receiving treatment or when they are admitted in hospitals to receive health care. For example, due to errors by doctors or nurses, a good number of patients have succumbed to their illnesses while receiving care in intensive care units in hospitals (Johnstone & Kanitasaki, 2007). On the face of it, such incidences could be seen as tragic, but they are unavoidable occurrences that emanate from unforeseen and acknowledged tricky situation intended to create anesthesia. Ideally, if all the stakeholders in health settings are carefully accountable for their actions, then some of these unfortunate occurrences could be averted. Although all professionals who play some role in an intensive care unit are competent and experienced, a sequence of careless actions could lead to the death of patients. Some of the factors that lead to these actions include lack of clear leadership, problems of cognition and perception, lack of culture and loss of situational awareness (Castle & Sonon, 2006). Lack of clear leadership causes confusion due to the absence of a specific person in charge of consultations throughout the process. This impairs the communication and decision-making process amongst the team members. Perception and cognition problems cause breakup of the emergency set of rules, thus causing pressure as there are numerous options to be considered which are not the most important considerations at that moment. In the process of operating the patient, the consultants may forget that the situation requires them to be highly attentive when carrying a certain procedure, such as inserting the breathing tube to save the life of the patient. This failure could be because they have lost the sense of severity of the situation or a sense of time (Castle & Sonon, 2006). The culture of the hospital defining a hierarchy of leadership with separate responsibilities could be a source of error during an emergency. For example, the nurses who come to the realization that there is an urgent need of an emergency kit in the intensive care unit may avail the kits on time but fail to remind the surgeons when the kits are not used. This is simply because they lack boldness despite the fact it is needed in such a desperate situation. Occurrence of many errors in health settings is believed to be a result of stress. In a situation of high pressure, different people have different responses. In addition, other human factors are highly sensitized during situations of high pressure, especially those factors that have high impact on cognitive and perceptive functions. In particular, the risk of errors being committed in health settings are heightened by factors such as teamwork, distractions, mental workloads, product/device design, and the physical environment (Reason, 2000). Synthesize the knowledge of the relationship between management issues and healthcare safety and quality. The management is charged with a crucial role of creating awareness regarding human factors and their relation to the patient’s safety. As such, the management has the responsibility of providing high leadership level, specifically in relation to the development of a constructive safety culture and entrenching human factors training in health care settings. The senior management of health organizations has a very important mandate of ensuring a safety culture in order to avoid errors while administering healthcare to the patients (Department of Health, 2000; 2001; Reason, 2000). Essentially, when the management of healthcare pursues a positive safety culture in their organizations, there is a perception that these organizations are informed, open and just. These efforts are achieved by ensuring that reporting and learning from mistakes is a normal practice of a health care organization. The commitment of the senior management to creating safety awareness is a very important attribute of a health organization culture, which protects the roles and interests of the patients as well as all the health workers (Mannion, Konteh, & Davies, 2008; Raleigh & Foot, 2010). A safety program for patients cannot be successful without the support of the management because its input is very crucial and cannot be delegated. As such, the culture that is required to tackle problems of medical harms and safety can only be directed productively by the senior management. Members of the senior management responsible for these roles include CEOs, executives, board members, and senior clinical leaders (Kristensen, Mainz, & Bartels, 2007). Essentially, the central role of management in ensuring safety in health settings includes the following: setting of strategic goals; establishment of value systems; alignment of efforts to attain the set goals; removal of impediments to enhance the work of the staff; sustainability and spread of effective systems; and ensuring observance of practices that enhance patients’ safety (Whittaker, 1999). It is important for the management of health care institutions to change the way they react to failures and mistakes. For example, this can be achieved by seeking the cause of errors rather than attacking those who committed them – this way, the culture in these institutions will change and solutions for problems will be found easily (Sherman et al., 2009). It is the responsibility of the health care management to prioritize the issues of patient safety while formulating strategic plans for their institutions. In order for the staff of health care organizations to perceive issues of health safety as strategic priorities, the management should be on the forefront in ensuring that safety is greatly emphasized (Sherman et al., 2009; Huber, 2006). The management should ensure that the safety of the patients is not just an ordinary objective but also a corporate priority. This is achieved by making everyone in the health care institution accountable for safety of the patients (Health Care Leaders Leading, n.d.). The management should discuss the safety error issues that have occurred in the past, since these issues are of strategic priority. Another way of achieving this is by pointing out the performance gap, which shows where the institution stands and where it ought to have been in terms of performance. Also worth noting is the management’ responsibility of providing instruments for measuring and assessing the institution’s performance for a particular time (Runciman et al., 2006; Inamdar, Kaplan, & Bower, 2002; Park & Huber, 2007). References Bogner, M.S. (1994). Human error in medicine (1st ed.). New Jersey: Lawrence Erlbaum Associates. Brand, C., Ibrahim, J., Cameron, P., & Scott, I. (2008). Standards for health care: A necessary but unknown quantity. Medical Journal of Australia, 189(5), 257-260. Castle, N. G., & Sonon, K. E. (2006). A culture of patient safety in nursing homes. Quality and Safety in Health Care, 15(6), 405-408. Department of Health (2000). Organization with a memory. London: Department of Health. Health Care Leaders Leading (n.d.). A Dana-Farber Cancer Institute executive describes the crucial role of leadership in driving patient safety. Retrieved from http://www.ihi.org/IHI/Topics/PatientSafety/ Huber, D. (2006). Leadership and nursing care management. Philadelphia: Saunders Elsevier. Inamdar, N., Kaplan, R., & Bower, M. (2002). Applying the balanced scorecard in healthcare provider organizations. Journal of Healthcare Management, 47(3), 179-195. Institute of Medicine (1999). To err is human. Building a safer health system. Washington: National Academy Press. Johnstone, M.J., & Kanitasaki, O. (2007). Clinical risk management and patient safety education for nurses: A critique. Nurse Education Today, 27(3), 185-91. Kristensen, S., Mainz, J., & Bartels, P. (2007). Patient safety – a vocabulary for European application. Aarhus, Denmark: SIMPATIE European Society for Quality in Healthcare – Office for Quality Indicators. 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Shared meanings: Preferred terms and definitions for safety and quality concepts. Medical Journal of Australia, 184, 41–43. Sherman, H., Castro, G., Fletcher, M., Hatlie, M., Hibbert, P., Jacob, R. … Virtanen, M. (2009). Towards an international classification for patient safety: The conceptual framework. International Journal for Quality in Health Care, 21(1), 18–26. Whittaker, M. (1999). Towards strategic quality management of health care. Journal of Health Management, 1(2), 215-248 Read More