The Health Care Services: Managing Patient Safety - Essay Example

? Managing Patient Safety. Introduction. Patient safety has increasing become a growing concern for both the health care practitioners and the community as a whole. However, research shows that despite public outcry, there are notable failures within the health care services that are likely to pose a threat to patient safety. The biggest challenge towards moving to a safer health system is changing the culture of blaming health professionals for errors to one in which these errors are treated, not as individual failures, but as opportunities to prevent harm and improve the system. (I.O.M, 1999). Harm occurs if a patient’s quality of life or health is negatively affected by any element of their interaction with health care. This would be as a result of patient safety incident, which is any healthcare related event that is unexpected, unintended, and undesired and which could have or did harm the patients. It is, therefore, upon the NHS to ensure high standard, as well as safe clinical care is maintained and make sure they are in line with the current technology. According to the department of health, patient safety needs to be prioritized, as far as health care system is concern. The resulting patient safety management knowledge continually heighten improvement efforts to better patients’ welfare such as applying lessons learned from industry and business, educating consumers and providers, adopting innovative technologies, enhancing the error and the reporting systems, and finally developing new economic incentives (Fleming, M, 2000). Arguably, researchers ought to investigate and find out the effectiveness of patient safety in the health care system. This, in essence, can help ascertain the measures that can improve the conditions if need be. In this paper, my major concern entails patient care as practiced in any health care services with major focus on medication safety based on analyzing the current issues of patient safety management and understanding of systems and human factors in maintaining patient safety. It is evident from research that as far as patient safety is concerned, medication safety is one of the major issues that is quite disturbing. In this regard, human factors, which correlate with medication safety, play a major role, in so far as patient safety is concerned and cannot be overlooked when dealing with such sensitive issue as patient safety. Negligence, as a human factor, has increasingly become one major factor that affects medication safety basically because of lack of concern among the health care practitioners. For instance, I remember one critical instant when a health care practitioner, acting out of negligence, failed to rescue the life of Elain Bremonung, a young woman who was admitted in the hospital for routine sinus surgery. During the anaesthetic, she had breathing problems and the attending anaesthetist was slow at responding to the situation, thus became unable to insert a device to open her airway. The most distressing thing about it is that the affected patient was in a critical state. If not for the alarm sounded by one of the friends of the affected patient, the patient would have passed on. Arguably, there were no grave consequences reaped on this incident, however, one thing that is clear is that medication safety is up stake in many of the health care systems. This incident clearly shows that human factors, as well as organization factors play a role in medical safety. This, therefore, calls for need to investigate the link between organizational and human factors in relation to patient safety. I have considered such issues in my presentation. Hence in doing so, I would come up with an incident that reflects the role of organization and human factors in patient safety and finally outline recommendations to the situation. Patient safety. Patient safety is the prevention, avoidance and amelioration of adverse injuries or outcomes stemming from the processes of medical care. It is also freedom from healthcare associated, preventable harm. A simple explanation to this is that when things are right, nothing terrible happens. In order to improve or maintain patient safety, errors have to be averted, minimized or at least recovered. Safety emerges from the interaction of the components systems, department or device (Coulter, A., 2011). Patient safety is part and parcel of health care quality. The concept of patient safety is paramount in preventing many of the patients who are harmed or die every year because of unsafe care or are injured while seeking health care. Patient safety is a fundamental principle practiced in health care. In every point of caring the patient, there are always certain degrees of inherent safety. Adverse events and reactions may result from errors in products, practice, procedures or systems. Patient safety perfections demand a complex systemwide effort, putting in place a wide range of actions in performance improvement, safety on the environment and risk management, including control of the infection, safe use of drugs and medicines, safe clinical practice, equipment safety, and safe, environmental care. Understanding the magnitude of this problem in primary care facilities and in hospitals is noble towards improving patients’ safety. In this regard, patient safety is referred as the mechanism by which organisation(s) ensure patient cares are safer. The National safety agency for patients outlines seven steps in safeguarding patients safety as follows: Building a safety culture, Leading and supporting your staff, Integrating your risk management activity, Promote reporting, Involving/communicating with patients and public, Learning and sharing safety lessons and last but not the least Implementing solutions to prevent harm. Safety of the patient is a new healthcare subject that emphasizes the analysis, reporting, and prevention of medical error that often causes detrimental healthcare events (Clarke, S, 1999). The magnitude and frequency of avoidable errors and injuries to the patient was not well identified until the 1990s, when several countries reported scarring numbers of patients killed and harmed and by medical errors (Colla, J.B, 2005). In recognizing that medical errors impact 1 in every 10 patients worldwide, the World Health Organization (WHO) terms the safety of the patient an endemic concern. Indeed, patient safety has stood out as a distinct healthcare discipline anchored by an immature yet striving and developing scientific framework (Donabedian, A, 2004). There is a vital trans-disciplinary body of research and theoretical literature that informs and disseminates the science and art of patient safety. Issues related to the absence of patient safety have always been a worldwide problem. During the first decade of this Century, there has been a national effort to improving patient safety (Fleming, M, & Wentzell, B, 2007). Safety of the patient is a global issue, affecting most countries at all levels of technological and economic development, and it makes one of the country’s most outstanding health care challenges. In accordance to the Institute of Medicine (IOM) (1999), they estimated that 44,000 to 98,000 persons die in U.S.A hospitals yearly as the result of collapse in patient safety and millions of patients worldwide are likely to suffer disabling pain and injuries or death yearly because of unsafe medical care. Healthcare facilities are becoming more responsive on the importance of transforming institutional culture for purposes of improving patient safety. The increasing interest in patient safety culture has been necessitated by the desire of health care providers on patient safety improvement efforts. The bodies of International accreditation such as the Joint International Commission (2009) pointed out that about 50 percent of their standards is related to safety. Beforehand, they had already established Patient Safety Goals Nationally (NPSG) in 2002 to help institutions address certain areas of concern in relation to patient safety. In the Philippines, there is the Health Insurance Corporation of Philippine or just Phil Health that accredits their hospitals Fleming, M., & (Wentzell, B, 2007). In addressing patient safety, the following has to be considered: Principles of patient safety, individual factors in patient errors, systems issues in patient errors, risk assessment machinery, the a patient safety culture, safety issues from practice, the international perspective of patient safety, effects of patient safety incidents, leadership styles and their influence of quality care. The fundamental concept of the science of patient safety is always patient centered, with a regulatory framework, based on the team and systems striving on performance in a specific cultural, social and economic arena. One of the most useful drivers for any institutional performance is accomplished comparative performance data that enable organizations and institutions to benchmark against similar organizations. However, the current data on clinical risk management outcomes is poor. Improvements in this sector need to be a priority, as without the accountability of the data and performance improvement needs can be met. These challenges are faced by most health services worldwide. In the past, risk management was left and seen as the role of the clinician alone. Structured clinical risk management, interfaced within the hospitals management framework, is now a relatively new discipline. The Scenario. Elain Bremon was a healthy and fit, young woman who was admitted in the hospital for routine sinus surgery. During the anaesthetic, she had breathing problems and the attending anaesthetist was unable to insert a device to open her airway. After 12 minutes, it was a condition of ca not ventilate, cannot intubate an anaesthetic emergency for which guidelines exist. For a further 20 minutes, four highly experienced consultants made numerous unsuccessful attempts secure Elain’s airway, and she had suffered prolonged periods with low levels of oxygen in her bloodstream. Early on nurses told the team that they had brought emergency kit to the room and booked a bed in ICU but none of them were utilized. 40 minutes after the start of the anaesthetic it was decided that Elain was to wake up naturally and taken to the recovery unit. When she was not able to wake up she was then taken to the ICU, intensive care unit. Elaine never regained her consciousness, and after 14 days the decision was made to withdraw the emergency equipment. This could be seen as a tragic event, yet unavoidable. It results from an unexpected but recognized complication of anaesthesia from the surface. However, the results could be different if human factors had been taken into considerations by everyone involved in the company. It is vital to appreciate the fact that every member of the team attending and treating Elain was experienced and highly competent, and yet the series of actions and events still resulted in her death. The investigation highlighted some of these factors: Cognition and perception - actions were not in accordance with the emergency protocol. In the pressure of that moment, many options were being considered, but they were not the only options that made the most sense in hindsight. Loss of situational consciousness and sensitivity – the stress of the situation meant that the four consultants involved became more focused on repeated attempts to insert the breathing aid. As a result of this, they deviated and lost sight of the bigger picture i.e. the length of time this attempt had been taking. The tunnel vision here meant that they had no sense of time spent or the severity of the condition. Teamwork – there was no leader in the team. All the consultants in the room were providing support and help, but no one individual was seen to be in charge throughout the process. This led to a breakdown in communication and decision making process and between the four consultants. Culture – Nurses saw the urgency early on and brought the emergency device to the room, and then informed the ICU, intensive care unit. They pointed out that these were available but did not raise their concerns when they were not utilized at the time of need. Other nurses who were informed of what was happening were not in a position to broach the topic. The attending team hierarchy made assertiveness difficult even though the situation was severe. The System factors. There is an overwhelming recognition in the human factors literature of the different levels of factors that can contribute to human error and accidents (Rasmussen, 2000). If the various factors are aligned appropriately like ‘Swiss cheese slice’, accidents can occur (Reason, 1990). The levels of system design are organized as follows: physical devices, individual behavior, physical ergonomics,, team and group behavior, management and organizational, behavior, legal and regulatory rules, and societal and cultural pressures. All levels of system design are related and interdependent to each other. In implementing changes toward patient safety, it is necessary to align motivation and incentives between the different levels. The case study of Elain Bremon above indicates that medical device for breathing aid were available, but it is evident how improvements in the design of medical equipment for patient safety did not occur because incentives between the different levels were not aligned. A medical equipment manufacturer brought in human factors errors after a number of events occurred in the above pressures situation. Probably the company did not take the initiative of training the medical personnel of equipment use. Some of the errors led to over deliveries of anaesthetic and patient died yet there were consultants and emergency kit was present. The nurses also pointed out that kits were available but did not raise their concerns when they were not utilized at the time of need. Other nurses who were informed of what was happening were not in a position to broach the subject. It is paramount that patient safety improvement efforts to be targeted at all levels of system design. In addition, there is a need to ensure that incentives at various levels of the system are aligned to support and encourage safe care. Parker et al. (2006) suggests that safety culture is affected by institutional changes, such as leadership change or the introduction of new processes and systems. This shows that safety culture is affected by the processes, practices and systems of the organization (Nieva, V.F, 2003. For example, an institution with a poor patient safety culture will have restricted safety systems, while an organization with best culture will have many systems within to promote and enhance patient safety. In this regard, it is possible to assess the extent to which processes and systems promote a positive patient safety culture by evaluating institutional practices that influence the culture. This approach is backed by Parker et al. (2006) and Zohar (2000), who have shown that patient safety culture consists of both abstract and concrete aspects. The concrete aspects of this safety culture are observable and tangible and can, therefore, be utilized to develop a list of organizational routines that support a positive patient safety culture (Brennan, P. F, 2004). Hospitals and health care institutions should develop a positive patient culture to promote and manage patient safety. Human factors. Given that all of us are humans, it means we are never perfect. Mistakes constitute our daily lifestyle. We are prone to mistakes, susceptible to emotional changes, but with proper memory for recollection of life unfolding. However, as rational beings, we are destined to forgive those who wrong us. This is also the case among the healthcare professionals who always strive to deliver quality treatment to service users, in good faith and with professionalism not to hurt or harm patients. However, it should be taken into consideration that they are all humans as per all of those are fallible. If such human elements are taken into consideration, those human behaviors leads to harming patients while delivering care that at time amounts to being tragic. It is noted that enhancing awareness and strengthening alertness of those latent factors aid in reducing the chance of harm to patient. Nevertheless, we should fully understand what human factors are. Human factors include all those factors that can affect people and their behavior. In a working scenario, human factors are the organizational, environmental, and job factors, and individual uniqueness which influence their behavior at work. Tens of thousands of patients are treated safely by committed and dedicated healthcare professionals who are motivated in providing safe and high quality clinical care. For the majority of patients, the therapies they receive always improve or alleviate their symptoms, and this is the best and positive experience. However, an unacceptable number of patients are always harmed because of their treatment or because of their admission to the hospital. In summary, common human factors that could increase the harm risk to the patients include: Device/product design, mental workload distractions, the physical environment, physical demands, teamwork and the process design The fundamental responsibility of health services to first, do no harm’ makes the reduction of care-related injury and illness a core task for health services and staff in health care institutions (Vincent, C, 2005). It is a considerable challenge faced by the health system and health care practitioners worldwide. Even the best people, with the highest levels of professionalism, skill, and commitment, will at a given time make mistakes. The challenge for institutions is to create an environment where errors are detected early, investigated, and systems are established to make sure that mistakes are not routinely repeated and that potential harm is minimized (Waller, M.J, & Roberts, H, 2003). If the best persons can make mistakes, then the best institutions learn from those mistakes, and use them to improve and promote their practices. In managing patients’ safety in relation to the dispensing stage would include confirming the expiration dates on drugs, reviewing patient medication profile, checking the integrity of the drug, being clear on proper use of the drug, clearing instructions for drug usage, clarify all questionable orders, understanding what the drug is used for, knowing patient allergies and last but not the least knowing patient history. In addition, monitoring stage of medications would require that laboratory tests are monitored and reported, effectiveness of therapeutic effects and side effects of medication monitored, and assess and monitor vital signs of the patient. Conclusion and Recommendations for practice The conclusive part of this paper entails, summary of the discussion held above. First, it was about an incident of a patient who was admitted in the hospital for routine sinus surgery. During the anaesthetic, she had breathing problems and the attending anaesthetist was unable to insert a device to open her airway. After 12 minutes, it was a condition of ca not ventilate, cannot intubate an anaesthetic emergency for which guidelines exist. This was because of human factors such as carelessness, negligence, incompetence, or can also be due to lack of training of the staff on duty. It was then the meaning and importance of patient safety identified and analyzed the system factors and human factors related to my example. Following this discussion, it is certain that, we are the key element that built up the problems and leaks in healthcare delivery, but if we learned the lessons of incidents comprehensively, a lot of tragedies could be avoided. There are many types of medical errors ranging from medication errors, patient abduction, equipment failure, surgical errors, patient assault, falls, suicide, mismatched blood transfusions, diagnosing and treatment stage (Westrum, R, 2004). Individual and system failure factors are the two specific categories of factors that have an impact on the incidence of medical errors. The individual factors are related to stress, distractions, increased workload, complacency, lack of education, lack of common sense and failure to follow procedures and policy. This has been demonstrated in the above case, for instance stress and of common sense has been demonstrated well in the shown cases. System failures may include inappropriate policy and procedures, poor systems of tracking to identify the cause and prevent of errors, and communication breakdown and lack of know how regarding these systems. In the incident, above system error has been well demonstrated by the communication breakdown between nurses and the ICU professionals. Situations contributing to more medical errors are the environment conducive to distractions, interruptions, tense/stressful, very noisy, a lax environment and poor communication. It has been established that most medical errors are not brought by individual mistakes, but by system error leading to a detrimental event. References. Ashcroft, D.M., 2005. "Safety Culture Assessment in Community Pharmacy: Development, Face Validity, and Feasibility of the Manchester Patient Safety Assessment Framework." Quality and Safety in Healthcare 14(6): 417-21. Bellamy, G.T., 2005. "The Fail-Safe Schools Challenge: Leadership Possibilities from High Reliability Organizations." Educational Administration Quarterly 41(3): 383-412.   Britten, N., Stevenson, FA., 2000. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ2;320:484-8. 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