Managing the Safety of Patients - Research Paper Example

? Managing Patient Safety Report Word Count: 3,080 Introduction Managing the safety of patients is a crucial aspect of healthcarethroughout the world, and it has become a large focus of many healthcare and international organisations, due to a strong focus on minimising adverse effects and unnecessary patient deaths. This report examines a patient safety incident that occurred within a hospital in the United States, where a patient with an ICD device underwent surgery without any complications. However, the device was turned off prior to the surgery and a combination of system and human factors resulted in the device not being reinitialized. This risked the life of a patient, and a subsequent cardiac event killed him as a result (Sullivan and Ferriter, 2008). The aim of this report is to examine this event in detail and determine what could have been changed to prevent this happen, and to decrease the likelihood of a similar event happening in the future. Patient Safety Advances in knowledge and technology have created a system of healthcare that is highly successful, and able to effectively treat a wide range of conditions. However, these factors have also led to the growth of the complexity of the healthcare system. This is an aspect of considerable concern, and the development of complexity brings considerable risk, and the potential of harm occurring to patients as the result of human or system factors (National Patient Safety Agency, 2004). There are many arguments for why the current systems of care are ineffective at preventing harm to patients, but one of these is that it has a strong reliance of systems and approaches that are outdated and based on previous techniques that are no longer relevant (Carayon, 2007). Whatever the driving factors, it has become clear that the safety of patients in healthcare is something that needs to be addressed, and preventable incidences of harm need to be minimised. There has been an increased interest and focus on health safety throughout the world, as well as in the scientific literature. Estimates suggest that approximately ten percent of all patients admitted into NHS hospitals experience at least one incident where patient safety is compromised. Furthermore, it would be possible to prevent a large number of these incidents (National Patient Safety Agency, 2004). Medical errors are a significant problem in the healthcare industry, and a 1999 report identified that up to 98,000 people die every year in hospitals as the result of medical errors that were preventable (Kohn et al., 1999). This report has become well known, and way one of the driving factors for the focus on patient safety. The interest in the area has generated many specific terms that are used to describe what is occurring within institutions, and the desire to prevent such incidents. Two prominent terms are patient safety and adverse events. The concept of patient safety is the prevention of any harm or adverse events occurring to the patient. In literature, the term is used prevalently, but defined rarely. For example, the 1999 report by the Institute of Medicine which spurred the focus on patient safety uses the term extensively throughout the paper, but the authors do not define what the phrase actually means (Kohn et al., 1999). It can be reasonably assumed that health safety is not explicitly defined, both because the term appears to have an intuitive definition and because this makes determining the exact meaning of the term difficult. However, understanding patient safety is a crucial aspect of effectively discussing or implementing this. Therefore, to approach this, we will first consider what an adverse event is, then examine how this definition can be used to help define patient safety. The National Patient Safety Agency defines an adverse event as “Any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS-funded healthcare”. This definition is also taken to apply to the terms patient safety incident and clinical error (2004, p9). Although this definition is specifically written for NHS hospitals within England and Wales, it is applicable to non-NHS hospitals within this region, and elsewhere in the world. This definition focuses on the fact that the incident was not meant to occur, and that it had the potential to lead to harm. Under this definition, it is not relevant whether the incident caused harm to the patient or not. Another definition of an adverse event is an injury that occurs to the patient as the result of medical management (or mismanagement) rather than an underlying disease or medical problem (Carayon, 2012). The largest difference between these two definitions is that the first considers the incident itself as the adverse event, while the second considers the injury to be the event. Carayon (2012) argues that the term serious medical error can be used to define something that either can cause harm, or has the potential to cause harm. Another approach to defining an adverse event has been taken by the World Health Organization (WHO), which developed a conceptual framework for classifying patient safety in 2009. In this report, the authors also consider an adverse event to be one where injury to the patient actually occurs, while an incident that caused no harm to the patient would be considered no-harm (World Health Organization, 2009). This follows the same trend identified in Carayon’s definition of an adverse event, specifically, that an event is not adverse unless it causes harm to the patient. The WHO defines patient safety as reducing the risk of unnecessary harm that occurs within healthcare to a minimum acceptable level (World Health Organization, 2009). This definition recognises that no matter how much control is in place, adverse events will still occur. This means that the purpose of patient safety approaches is to minimise risk and maximise safety wherever possible. Another definition of patient safety is simply that it is the freedom of the patient from any injury that occurs accidently (Kohn et al., 2000). On the basis of these definitions and the way that adverse events are defined, it can be argued that patient safety can be considered as an approach that attempts to reduce the number of adverse events that occurs and their likelihood. The Scenario Implantable cardiac defibrillators (ICDs) are devices that are used to prevent cardiac arrhythmias that could lead to the death of patients. They are implanted into the hearts of patients and use electronic signals to correct rhythms within the heart (Stevenson et al., 2004). These devices are complex, and the policies for how these should be managed continue to grow and change, as well as the technology involved (Crossley et al., 2011). The patient safety incident that is being considered in this report occurred with a middle-aged man who had an ICD following elective surgery that occurred without event. Interference from surgical equipment has the ability to significantly interfere with an ICD, so hospitals either place a magnet over them during surgery, or turn them off, reinitializing them after the surgery is complete (Stevenson et al., 2004). However, there is no consensus document for how policies should be developed for ICD devices, and as such, hospitals take different approaches (Crossley et al., 2011). In this patient safety incident, the ICD was turned off prior to the surgery, and all aspects of the surgery proceeded as planned. However, the ICD was not reinitialized and the patient died from a cardiac incident, which the ICD would have prevented (Sullivan and Ferriter, 2008). System Factors When considering patient safety within the healthcare system, the factors that influence the likelihood of adverse events can be broken down into two categories. These are system factors and human factors, which will be discussed in detail in this section of the report and the following one. System factors refer to aspects of the healthcare system itself that lead to the presence of adverse events. Some examples of system factors include the work environment, the specific policies that are in place, legislative policy and the natural environment (World Health Organization, 2009). The concept behind this factor is that it is aspects of the organisation, its structure, or physical components that are influencing patient safety, rather than the people working within it. A system itself can be defined as a whole which contains parts which are connected to one another, and interact in an organised manner. Often a system will comprise of many smaller systems and different elements (Waring, 1996). This definition includes a wide range of different types of system, including healthcare. A system may be effective, or it may be ineffective depending on its design, components and the way that these interact with one another. For most systems, the ideal situations is to increase efficiency, which tends to also result in fewer errors. An ICD device is a complex mechanism that can be confusing for surgical teams and nurses, as the technology regularly changes and recommendations about how these devices should be managed is a continually changing field. A significant amount of the literature available to surgical teams is outdated or contradictory (Crossley et al., 2011). Determining how frequently adverse events involving ICDs occur is difficult, because many reports can blame these occurrences on other drivers, such as the patient having a weak heart or a surgical complication. In some cases, it may be difficult to determine exactly what happened because of factors influencing one another and the lack of reports made in cases where the event was an adverse incident, and not a complication of surgery. One system factor that played a crucial role in the patient safety incident was that of organisation policy. While the policy of the institution clearly stated that the ICD device should be turned back on following surgery, several aspects of this policy were limited. Of particular importance, there was no information given about who was responsible for reinitializing the device, or who should check to ensure that this was done. As such, in this particular case, each person involved assumed that someone else had turned the device on and no one remembered to check to see whether it had actually been done. This issue is related to the organisation and to the healthcare industry, as there are no universal policies for how ICDs should be managed in the surgical setting (Crossley et al., 2011). If the policies of the institution had specified who was responsible for turning off the device, it is more likely that this would have been achieved. Some studies have identified that a lack of staff members or a too high workload as a system factor that results in a loss of patient safety due to issues such as diverted attention (Carayon, 2010). In the situation being examined in this report, all staff members within the department who could have reinitialized the device had a large number of other roles. By having staff members with little time and a large amount of responsibility, the system creates an environment where it is difficult for staff members to do their jobs properly. This partly occurs because the large number of roles that staff are required to play results in them attempting to quickly move from one role to the next, and can result in aspects being forgotten (Carayon and Gurses, 2008). As such, the system problem could be evaluated as a lack of staff members, or as a work environment that encourages speed at the expense of quality. A final important system factor is the lack of controls present. Within any system, controls are important to ensure that processes occur as they are meant to, and give people the ability to identify and address any factors that may contribute to patient harm (World Health Organization, 2009). The presence of appropriate checking procedures is important for ensuring patient safety, this is particularly important in cases where care is complex, or multiple teams of people are involved (Carayon, 2010). In this patient safety incident there should have been measures in place to ensure that there were people responsible for determining that the device had indeed been turned back on. These system factors show specific areas where the system within the institution itself that contributed to the patient’s ICD device not being turned back on. Human Factors Human factors are a significant issue in the healthcare environment, because people have the ability to make mistakes, to misinterpret the information that is in front of them, to overlook factors or to forget something that they are meant to do. Sometimes called ergonomics, human factors is considered to be a scientific discipline that examines the way that humans interact with one another and with the components of a system. The term also applies to the application of principals and theory in an attempt to maximise the well-being of people within the system and the performance of the system as a whole (Carayon, 2012). In this case, the system that is being considered is the healthcare system, with a strong focus on patient safety within institutions. Humans are a crucial part of the healthcare system, and there are many different types of people involved, from a range of professions and backgrounds. It is crucial that these people are able to work effectively as individuals and also as part of a team. People may be resilient, and able to be effective in a range of situations, however they are susceptible to stress. Stress is just one of many factors that can lead to a decrease in performance (Jenkins, 2011). As such, the human component of the healthcare system is important to be aware of, as it can have a substantial effect on the safety of patients. One way of considering human factors and how they can lead to errors in healthcare, is what is known as the Swiss cheese model. Under this approach it is argued that for a system there are many different levels that act as defences, these could include both human elements and components of the system. In the Swiss cheese model, each of these levels of defence has holes. If these holes line up with one another, then an error occurs (World Health Organization, 2008). Perhaps the most important human factor that occurred in this patient safety incident is the lack of communication between staff members. This is often considered a significant human factor in patient safety (World Health Organization, 2009). Good communication between staff members helps to ensure that everyone knows what is occurring, and that all functions of the team are adequately covered. A study examining human factors in healthcare found that poor communication occurring between nurses and physicians was the primary cause of errors (Carayon, 2010). In this patient safety incident, good communication would have ensured that staff members knew that someone needed to turn back on the ICD device, and this would have made it more likely that device would not have been forgotten. Communication is particularly important, because the current healthcare industry often involves a team that delivers care to the patient, which may consist of half a dozen or more individuals with different specialities and skills (Watcher, 2004). If these people do not closely coordinate with one another, then there are many avenues where things may go wrong. In the case of a patient with an ICD device who is undergoing surgery, there are several different groups involved, including the surgical team and the nurses. One recommendation has been that hospitals make use of an ICD team whose specific role is to find out information about the ICD and to convey it to the other groups responsible for the patient (AORN, 2011). The use of a team like this would significantly help to increase communication between staff members, which would also potentially reduce the number of adverse incidents. A second human factor that played a substantial role in the error that occurred with not reinitialising the ICD device was that of memory. It could be argued that the incident occurred primarily because the people who were responsible for restarting the ICD device, and who usually did it as part of routine care, forgot to do so. Specifically, this represents either a failure or a lapse in attention (House of Commons, 2009). Relying solely on memory to ensure that a task gets completed is a dangerous approach, because human memory is not always efficient, and people often forget things that they do not mean to. This is important to be aware of in the healthcare environment, because a poor decision based on forgetting something could have a significant impact on the safety of the patient. Conclusion This report examined a patient safety incident occurring within a hospital, where a combination of human and system factors resulted in a patient’s ICD device being turned off as part of an established procedure for surgery, and not being reinitialized after the surgery was complete. This is a substantial problem, as ICD devices have the ability to prevent fatal arrhythmias from occurring, and the patient did experience an arrhythmia following the incident, although it was not fatal. Systems errors that contributed to this event were the lack of detailed policy that stated whose role reinitializing the device was, as well as a high workload on staff members and a lack of controls within the system. Human factors were also a significant issue in this situation. In particular, there was a lack of communication between staff members and people who were responsible for reactivating the device forgot to do so. When examining an incident where patient safety has been compromised, it is important to consider what aspects of the system and the people within it contributed to this problem. Without doing this, the areas for improvement cannot be determined. Suggestions can be made on the basis of these observations. For the system factors, the development of a more comprehensive policy document detailing who is responsible for turning on ICD devices following an operating procedure and control mechanisms for determining whether this has been achieved, such as designating one or two people to check, or requiring a form to be signed within a few hours of surgery. This would make adverse events such as the one discussed in this paper less likely to occur. To counter the human factors, the control mechanisms suggested here would play a significant role. 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