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At my care facility, we have had a system to monitor errors, and this is in alliance with the Patient Safety regulations set by the state and the World Health Organization (WHO). These system, however, consists mostly of complying with rules and filing of incident reports after an error was found. This reactive system lives little room for being proactive and catching errors before they happened. Therefore, as of last year, our facility has implemented guidelines that are more proactive in nature. Some of the priority areas as outlined by the World Health Organization’s World Alliance for Patient Safety and the Collaborating Centre are to do quarterly training in identifying and reporting medical errors, implement reporting guidelines that are not punitive in nature, but rather informative; this way no one is afraid to speak up, and lastly, identify the events that are “near misses” and develop a plan to make these less frequent (Grawn, Thom & Walters, 2015).
The Institute of Medicine and Joint Commission published a study, “To Err Is Human”, which discuss in part that healthcare teams who fail to collaborate have increased mortality and failure-to-rescue (deaths within 30 days of admission among patients who experienced specific complications) rate” (Grawn, Thom & Walters, 2015). Nowadays there are partnership recommendations in position for healthcare facilities demanding implementation of “interdisciplinary practice plans” for accreditation by Joint Commission (Fewster-Thuente & Velsor-Friedrich, 2008). Effective communication is crucial to reducing medical errors and improving patient outcomes. The opportunity to act as a healthcare team is essential for improved patient care and the opportunity to provide care that’s “patient-centered and valued” (Ezziane et al., 2014).
The Institute of Medicine’s four-pronged approach to reducing medical mistakes are: “(1) an analysis of errors at your practice site that have caused some degree of patient harm, and (2) an analysis of your aggregate medication-error data. The other 2 prongs, of equal importance, are both proactive in nature and include (3) an analysis of “near misses” (errors that have the potential to reach the patient or cause patient harm) and (4) an analysis of errors that have occurred in other organizations” (Westrick & Dempski, 2009, p. 117).
These elements entail being reactive, being proactive, analyze the mistakes, and correct them. All of these are reportable and should be taken into consideration at organizational evaluations consistently.
Grawn, S., Thom, F. & Walters, I. (2015). Building efficient medical teams in professional medical care. Journal of Organizational Management, 16(9), 28-36. doi:10.1108/14777261211251508
Fewster-Thuente, L., & Velsor-Friedrich, B. (2008). Interdisciplinary collaboration for healthcare professionals. Nursing Administration Quarterly, 32(1), 40-48. doi:10.1097/01.NAQ.0000305946.31193.61
Westrick, S. J., & Dempski, K. (2009). Essentials of nursing law and ethics. Sudbury, MA: Jones and Bartlett.
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