Systems in Organizations for Safety and Improvement - Essay Example

Systems in Organizations for Safety and Improvement An error in health care industry is a fatal mistake more often than a silly blunder. Atthe same time, it is nearly impossible even to imagine a health care professional who would never make a mistake. When more than one persons are working together, such circumstances of conflict and misunderstanding arise. Such situations make the service of the health care professionals appear very ineffective for their knowledge and aspirations. It is important in such delicate and significant profession to learn how to work to the perfection while working on it. The systems are to great extend designed to prevent errors where they commonly occur in hospitals, such as on the doctor's prescription pad and during the nurse's medication rounds (Don Fienley). It is a fact that there is actually a medical revolution as far as medical improvements are concerned, such as fertility treatment, cancer cures, cardiac care and AIDS management are some of them to mention, on the other hand, in the United States health care system often fails to deliver on the promise of science it employs (Spear S. 79). This paper will look at some of the possible errors in this field and their remedies to prevent harm and injuries to the public. Medication Errors An earlier study showed that as many as 98000 people succumb to medication errors each ear in United States hospitals (Burke J). If this is the case of the health care conditions of country which leads the world in medical science, the situations in the third world can be beyond any calculations. Firstly, the medical errors include mistakes such as administering wrong dose, wrong drug or wrong time. Then, the eventualities such as misread prescription due to poor handwriting, mismanagement due to look-alike and sound-alike medicines and adverse drug reaction. Broadly, every nation and governments have made every possible step to make sure that the health care professionals are typically intelligent lot. The world is far from rewarding the health care professionals according to the patient out come rather than the number of patients they treat or mistreat. If the system gets to such a point the economic encouragement may keep the professional motivated and committed till the end. The hospitals and organizations are to integrate systems to improve primary care, nursing care, medication administration and a great lot of clinical processes. All this improvements will have a direct impact on the safety, quality, efficiency, reliability and timeliness of healthcare (Spear S. 79). Improvement and understanding will only take place when the gap between the health care system and the professionals working in it will narrow. Communication Errors It is common knowledge that poor communication will lead to adverse effect and results. Unless and until all in a team becomes completely sure of the situation that must be dwelt with and work that is to be completed and who are responsible for what aspect of work, moreover, the way it should be accomplished, the chances of error will always be there. When a problem arises in between a task the best way is for everyone to work closely around the problem. 80% of errors were initiated by miscommunication, including missed communication between physicians, missing information in medical records, mishandling of patient requests and messages, inaccessible records, mislabeled specimens, misfiled or missing charts, and inadequate reminder systems (Smith Peter). Most of the communicative error will round up to one staff member's failure to inform the other staff member of a patient's condition or verbal instructions are misunderstood. Often, a subordinate is smart enough to identify the problem but bit nervous to mention it to the senior who may not give the deserved appreciation for the hard work. Lack of proper and purposeful communication often ends up in a failure to perform medical procedure properly for example placing a feeding tube into the lungs and cutting an organ accidentally. 'A 2003 study by JCAHO documented that communication breakdown was the root cause of more than 60 percent of 2,034 medical errors, of which 75 percent resulted in a patient's death. In other words, 915 people died as a result of a communication error' (Health stream). There must be a point when the whole of the industry realizes that we can not allow the preventable error to be going on for ever. Operational Errors Misread medical orders, missing lab results and misread lab results are the main operational errors. The operational errors are those which do not go as expected. But often the problem could not be investigated and dwelt with immediately. In many situations it takes a long time before the organization come up with an effective counter measure. The remedy should be a matter of reducing defect, improving safety in the hospital improving responsiveness. "A 68 year old woman bates called Mrs. Grant had been recovering well from elective cardiac surgery. When all of a sudden she began to develop seizures. Her blood was drawn for testing, and she was rushed for a CT scan, which revealed no hemorrhages, mass or other obvious cause. When she was returned her room care givers saw from her blood test results that she was suffering from acute Hypoglycemia, and they tried unsuccessfully to raise her sugar level unsuccessfully. She quickly fell into coma and after seven weeks her family withdrew life support. A subsequent investigating revealed that at 6.45 on the morning of the incident, a nurse had responded to an alarm indicating that an arterial line had been blocked by a blood and he had meant to flesh the line with anticoagulant, heparin. There was however no evidence that any heparin had been administered" (Spear S. 84). The incident just simply explains the helpless situation which at times can be severe and close. Fixing the Health Care System 'At a nurses station at busy Metropolitan Methodist Hospital, Dr. Randy Panther pauses to check the Caller ID on his incessantly ringing cell phone. Then he uses a high-tech device called an electronic prescription pad to order antibiotics for a patient's infection. On the screen, a pop-up window warns that the patient has a drug allergy. The computer suggests a safer choice' (Don Fienley). In another section of the same hospital, continue to explain Don Fienly 'nurse Esther Garcia is distributing medication from a cart topped with a laptop computer and a hand-held bar code scanner - the kind used by supermarket clerks on bulky items like 20-pound bags of dog food. First she scans the bar code label on a dose of medicine prepackaged by the hospital pharmacy. Then she scans the bar code on a patient's hospital bracelet. The laptop informs her she's giving the patient the prescribed dose. These systems were designed to prevent errors where they commonly occur in a hospital - on the doctor's prescription pad and during the nurse's medication rounds. Some research suggests that hospitals using both systems could eliminate most medication errors, innocent mistakes that can cause grievous injury to some patients and kill others outright'. The American health industry has brought forward amazing results in the application of the technological system to day to day activities of the hospital. They hope to completely avoid the error making and thus the hospitals will regain their confidence to act upon. Mistake do happen, but most of the time when mistake takes place it is not personal issue of a professional, but a system error which would have been avoided with a system working round the clock. "As the sedatives course through the veins of the elderly patient lying on his side at the Audie Murphy Veterans Hospital in San Antonio, nurse Truthann Rivas calls a time-out. Everyone in the procedure room comes to a halt. "This is Mr. Everette. He's here for a colonoscopy. Are we all in agreement" Rivas calls out over the moan and hiss of medical equipment. "Yes," comes the muted response from everyone but the sleeping patient. It's the fifth colonoscopy of the morning for Dr. Lawrence Siegel and his team. Each time a new patient is wheeled in, VA rules require a time-out to prevent the most fundamental of medical mistakes. "The main thing," Siegel said, "is to be sure the patient is the correct patient."The VA is the largest health care system in the nation. with 153 hospitals and 919 clinics. Although the system is roiled by other problems and scandals, patient safety groups praise the VA for its efforts to reduce errors, including such regimens as the presurgery time-out to verify the patient's identity. The VA also leads the country in the use of computerized provider order entry and bar coding, and it pioneered the idea of disclosing errors to patients" Here is another great effort to establish a system to avoid the practically wrong dose and avoid miscommunication. Aiming and successfully implementing a system is not easy as it can cause the hospitals actually to lose money by providing safer care. For example, when Utah's Intermountain Healthcare hospital chain improved its system for prescribing heart patients the proper medications on discharge, rehospitalizations were reduced by 900 beds a year. As a result, the hospital lost $3.5 million in revenue (Nalder E and Crowely C). Integrating Toyota Production System The Toyota production system has played significant role in Toyota's performance and, more specially, the much spoken over error free manufacturing units. The whole metal of the Toyota can be captured in four basic rules. They are a) All work shall be highly specified as to content, sequence, timing and outcome. b) Every supplier customer connection must be direct and there must be an unambiguous yes or no way to send request and receive response c) The pathway for every product and service must be simple and direct d) Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization. Adopting this explicit rule the team work is being created as a part and parcel of the work culture. The situation of being ignorant of what is going on or to be done will not exist among the professionals anymore. It becomes a practice and possibility to team train the workers bringing in an awareness of the effective service to the patients and clients. Every move and treatment method administered in to person will have a particular path that follows, thus enabling a single and simple way of perfection to follow for the changing staff at the shift's changes. There can also be advanced medical record implemented so that the advanced functions can alert the caregivers to new lab results and high light abnormal results. . Work Cited Burke, John. "Infection Control - A Problem for patient safety" New England Journal of Medicine. February 2003 Fienley Don. "Hospitals Slow to Use Technology to Halt Errors" San Francisco Chronicle Monday, August 10, 2009. Accessed on December 14, 2009 http://www.sfgate.com/cgi-bin/article.cgif=/c/a/2009/08/09/MNN9191UJC.DTL Nalder E and Crowely C. "Secrecy Seals Medical Mishaps from Public View" home of the San Francisco Chronicle August 9, 2009. Accessed on December 14, 2009 http://www.sfgate.com/cgi-bin/article.cgif=/c/a/2009/08/09/MNN9191UIJ.DTL Smith, Peter, et. al. "Missing Clinical Information During Primary Care Visits," The Journal of the American Medical Association. February 2005. Spear Steven. "Fixing Health Care from the Inside, Today" Harvard business review September 2005. Read More