Quality Improvement in Health Care Examine Errors at Place of Work

Question:-

Please reflect on how actual or potential errors you see in your place of work could be examined. What is impacting the error, do any fall under the Red rule, what governmental organizations could help? 

Answer:-

I have observed that there are significant issues in different forms of communication which can compromise patient safety. Even near miss errors are also not reported. Disclosure of the errors are also not done appropriately to the patients, their families or even the management. Moreover, I found ethical issues is the reporting and disclosure mechanism as well. Human beings are prone to errors but in my opinion, these can be fixed by acknowledging the error first. There should be sufficient error reporting mechanisms in place. Reporting of errors should be made mandatory and also voluntary along with some incentives. The traditional verbal and paper reports are in force but there is lack of supervision. Also, there is need to promote the culture of patient safety. To inculcate this culture mandatory patient safety drills should be part of the nurses’ orientation and training programs. Another option to encourage reporting is the simplication of the reporting process. Modern online tools and standardized excel sheets can be used to automate the process. The patients are also a good source of information. Therefore, patient feedback should be encouraged at all times which goes beyond the normal “rate your experience” feedback. Supervisors should engage in conversation with the patients to understand where most of the errors are happening. Also, there should be clear disclosure policies. Besides a GEMS (Genetic Error-Modeling System) can be used to detect the most commonplace errors. Also Team STEPPS is an important mechanism to ensure patient safety by addressing the core of the medical team related issues (Agency for Healthcare Research and Quality, 2020).

The management needs to bring a change in perception about errors. It can be quite undermining for the medical professions to treat errors as individual failures, rather the mindset should be that errors are scope for improvement. The mentioned issues do fall under the purview of red rules. These rules would provide clarity on unacceptable disclosure and error issues and these should be strictly followed and in case of violations the person who committed violation should be barred from providing service (Jones, L.K; O’Connor, S.J, 2016). Some examples could be the use of bar code readers for medications and marking of incision site before a surgery is initiated. The Institute for Safe Medication Practice and The U.S. Agency for Healthcare Research and Quality (AHRQ) would help in the implementation of these rules. They would ensure the legal compliance of patient safety by supervising the implementation of red rules (Finkelman, 2018).