The Causes of Medical Errors - Report Example

Week 8 essay Root cause analysis technique is critical in analyzing the causes of medical errors. Poor communication and poor training of healthcare providers will lead to non-adherence to established operating procedures and processes in the health provision. Medical errors lead to death, injuries, suicides and other post operation complications. Risk operations like thoracic operation may result to post operation complications thus the healthcare provider should follow all the established procedures. Week 8 essay Introduction Patient safety is a critical part in the deliver of quality healthcare (Williams & Wilkins, 2007). Healthcare institutions should establish comprehensive healthcare programs to reduce the medical errors. Medical errors are the failure of the planned action or use of the wrong plan to achieve the medical objectives. More than 100,000 people die each year due to medical errors. Examples of medical errors include wrong disease diagnosis, wrong treatment, insufficient patient information collection and inefficient processes that delay administration of medical care. Medical errors lead to significant costs in the economy like lost wages, increased medication costs, injuries and disabilities and low patient satisfaction (Cohen, 2007). Although healthcare delivery is a high risk undertaking, healthcare delivery systems can be structured to reduce the possibility of medical errors through increasing patient safety and reducing exposure to wrong medication and diagnosis. Patient safety is enhanced by an organizational environment that promotes the early detection of harm and delivery systems designed to reduce the medical failures (Banja, 2005). For instance, the timely administration of antibiotic medication will depend on the efficient processing of the diagnosis information and order information. Complexity of internal processes such as diagnosis procedure, clinical medication and operation room activities may lead to medical errors (Banja, 2005). Problem statement Proper organizational design will lead to patient safety and reduction of medical errors. In order to reduce medical errors, organizations should implement risk management methods that increase patient safety by reducing medical errors. Poor communication among healthcare workers and failure to follow established operating procedures are the root causes of medical errors (Williams & Wilkins, 2007). Inadequate health provider training and fatigue may lead to medical errors. The health facility should be free from noise or any other distractions that may lead to poor attention of the healthcare provider. The proper identification of patients through proper medical record keeping and effective communication will enhance patient safety. Many wrongful site surgeries and patient falls occur due to wrong disease diagnosis and medications (Cohen, 2007). Position Root cause analysis can be effective in reducing medical errors. Poor communication and poor operating procedures will lead to post operation complications or death of the patient. There are six common medial errors. The first medical error that can occur is diagnosis error that may be caused by the use of the wrong methodology or failure to follow and monitor the diagnosis tests (Banja, 2005). The second medical error is the treatment error that is caused by utilization of the wrong procedure or operation. This error includes the delays in the provision of treatment or inappropriate treatment. The third error is the communication error that may occur due to lack of effective communication and failure to inform the patient of the medical condition and desired treatment. A fourth error that may occur is the systems error that is occasioned by inadequate and inefficient processes and procedures (Cohen, 2007). Equipment malfunctioning and accidents in the health facility are common examples of the system error of medical errors. Another common error is the medication error that mainly occurs due to wrong prescription, administration and dispensing of the wrong medication to the patient (Williams & Wilkins, 2007). The last and common medical error that leads to many injuries and patient deaths is the performance error, and include the surgical errors and performance of operations on the wrong site of the patient body (Banja, 2005). Supporting work Root cause analysis Root cause analysis (RCA) can be utilized to identify and analyze the causes of medical errors in the operation room. RCA analysis will identify the chain of events that led to the medical error. This is a process focused framework for analysis the error whereby active and latent errors occur. Active medical errors are committed by the medical personnel in direct contact with the patient. Some of the examples of active errors are the unsafe operating procedures and wrong medication that may lead to cognitive malfunctioning such as memory lapse (Leaper & Whitaker, 2010). Latent failures are the errors that are not directly associated with the caregiver but the result from the healthcare environment like inadequate and poorly trained healthcare staff. Equipment failure and time pressures may lead to medical errors (Leaper & Whitaker, 2010). RCA can be used to uncover the causes of medical errors in the health facility. The first step involves setting up a team to investigate the cause of medical errors. The team should include people from all the departments including nurses, lab technologists, physicians and pharmacists. The team may also include the staff who were directly concerned with the medical error. The team should discuss safety issues that can be implemented to reduce the medical errors (Cohen, 2007). The second step involves in-depth group discussions of the details of the medical error. The team should discuss the time the event occurred and departments that were concerned. The team should also discuss the impact of the event on the other departments. A flowchart should be utilized to show the processes that followed the medical error thus allowing for easier identification of the process gaps (Cohen, 2007). The next step will entail analysis of reasons for the medical error occurrence and how the event occurred. This entails identifying the lapses in the processes like the medical documentation process or the drug prescription criteria. Another process that is prone to medical errors is the laboratory tests (Leaper & Whitaker, 2010). The next step is the organization and panning of the medical processes. For instance, the team should identify ways of labeling blood specimens and documenting patient symptoms. All the likely medical errors should be identified at this stage together with the measures of combating such errors. For instance, improper patient identification and unclear labeling of drugs are contributory factors to severe medical errors. The results of the changes should be evaluated after certain duration to identify whether the risk management method is effective. Incident reports and chart audits should be maintained to track risk management in the healthcare facility and health delivery processes. The incident reports should not form part of the patient medical records but should only be utilized to understand the cause and impact of the medical error (Leaper & Whitaker, 2010). Pre-operation room errors Several medical errors may occur at the pre-operation stage. One of the errors is the failure to identify drug allergies. Some medicines have a high incidence of allergic reaction thus the medical personnel should identify the presence of allergies before prescribing the medication. Another medical error is the delay in treatment (Leaper & Whitaker, 2010). The delays in surgeries may result from delayed medical tests, incomplete treatment and the inability to locate the entrance to the emergency operation room (Leaper & Whitaker, 2010). Most frequent medical errors at this stage are related to personnel fatigue or concentration distraction. Unusual time pressures may lead to wrong blood transfusion or diagnosis of the wrong medical condition. Pre-operation errors will lead to the operation room errors (Naylor, 2002). Breakdown of communication between the healthcare provider and the patient will lead to poor diagnosis tests. Poor handwriting may lead to misunderstanding of the medical condition and treatment requirements at the operation room. Mislabeling of medicines and diagnosis reports will lead to the wrong site surgeries and wrong medication that ultimately lead to patient injury or death (Leaper & Whitaker, 2010). Operation room Sentinel events in operative and post-operative complications may not occur in emergency situations. Some of the procedures commonly involved in operative or post operative complications include endoscopy, open abdominal surgery, neck surgery and thoracic surgery. The procedures that result in most of the complications include feeding tube insertions, imaged directed percutaneous biopsies and open orthopedic procedures (Leaper & Whitaker, 2010). The most common medical error encountered is lack of effective communication among the healthcare personnel involved in the procedures (Naylor, 2002). Incomplete assessments before the operations and failure to follow the prudent operation procedure also result to post operation complications (Naylor, 2002). Another leading medical error is the unavailability of the necessary health care personnel during the operations (Lehne, 2004). For instance, the physician may lack an assistant like nurses or technicians to repair malfunctioning equipments (Lehne, 2004). According to the Root cause analysis, improving the physician training and effective communication channels will lead to as decline in the medical errors. Physicians should have effective training on radiology. According to root cause analysis, improvement in communication and adherence to the correct procedures avoid the medical errors thus lowering chances of post operation complications and patient deaths (Lehne, 2004). Counterargument According to the opponents of Root cause analysis, the risk management technique is not straight forward since barriers may be encountered while identifying the root causes of the medical error. Critics assert that root cause analysis is time wasting since time must be spend on analyzing all the incidents that have occurred in the health facility. RCA is not effective risk management technique since it focuses on the past medical errors and how to prevent the reoccurrence, but does not anticipate new forms of errors in the medical processes. After the occurrence of a medical error, the relevant authorities should investigate the cause of the error. Action plans All health care facilities should implement measures to ensure patient safety and reduce medical errors. Medical errors are either active errors or sentinel events that may lead to patient complications. Effective communication among the healthcare providers is essential. Additional training should be provided to all the healthcare providers on patient record keeping and operating procedures. The health facility should have established and proved procedures that should always be followed in all the processes. An incident report should be maintained to track the root causes of medical errors (Banja, 2005). Conclusion Root cause analysis technique can be utilized to monitor and control medical errors in the health facilities. The design of the health facility should improve the patient safety. Some of the safety design principles include the need to reduce noise and minimize staff fatigue. The design should minimize patient falls, operative and post operative complications. The design should reduce instances of death and patient injury due to wrong medication and medical tests. The design should ensure proper record keeping and access to patient information. The design should be flexible and adaptable to future changes in the health facility. Patient safety should be centered on the physical nature of the health facility, the efficiency of the health delivery processes, and the qualification and abundance of staff. All equipments should be in proper working conditions while staff should not be overworked. References: Banja, J. (2005). Medical errors and medical narcissism. Sudbury. Jones and Bartlett Publishers. Cohen, M. (2007). Medication errors. Washington, DC. American Pharmacist Association. Leaper, D & Whitaker, I. (2010). Post-operative complications. Oxford. Oxford University Press. Lehne, R. (2004). Pharmacology for nursing care. London. Rutledge. Naylor, R. (2002). Medication errors: lessons learnt for education and healthcare. Abingdon. Radcliffe Medical. Williams, L and Wilkins, L. (2007). Best practice: evidence-based nursing procedures. Philadelphia. Lippincott Williams & Wilkins Read More