The subject of Patient Safety is rather ironic as hospitals have always been considered the safest place to be, where qualified medical staff keeps a 24/7 watch and all the medicines, equipment, and support staff are just a call away. Unfortunately, data proves otherwise. A recent study conducted at Yale School of Medicine stated that approximately 22,000 patients die of preventable medical errors in the US. If these statistics hold true for the US, we can only imagine the rate of medical errors in third-world countries.
By nature of its work, the healthcare industry has a
high-adrenaline environment. Dozens of healthcare workers have to coordinate to
care for a patient and one simple misunderstanding or a slight delay can
drastically affect the patient’s well-being.
So, how do we eliminate these errors? How do we find staff who will never make mistakes?
The most important aspect of both Quality Improvement
and Patient Safety is to focus on the system and not on the person. It is not
possible to find an error-proof human, but it is possible to strengthen the
system by implementing double checks, reminder tools, and automation where ever
possible.
An example could be that the risk of transfusing the wrong blood to a patient can be lowered by using a double signature method to ensure both doctor and nurse have verified the unit, or in more advanced settings the scanning of bar-coded wrist bands can be used to ensure the blood has in fact, been crossmatched for this patient.
Despite all the technical advancements and checklists,
there will always be some sneaky employee who will find a loophole and use it
to cut corners. Therefore, along with the process improvements, employee
awareness is the prime target. All healthcare workers should acknowledge the
impact of their work on human lives and how the slightest negligence can harm a
human life permanently.
Whether the employee is a nurse directly caring for the patient or chef in the kitchen ---- patient safety is everyone’s responsibility. If anyone in the hospital, witnesses a safety risk or potential hazard, he or she should take ownership and report the incident without fear of repercussions.
Patient Safety is a part of organizational culture and
to be successfully implemented the commitment to patient safety should be seen at
all levels, from senior-most to junior-most employee. It has been noted that Managerial
staff often prefer to brush the error under the carpet after placing the blame on
one individual. This mindset has to be changed as we will not be able to find
and correct the root cause unless we discuss the incident with all stakeholders
and focus on preventive action rather than disciplinary action.
To err is human, but to hide a medical error is criminal. We need stricter vigilance and deeper investigations of medical errors with a clear action plan to prevent future recurrences. It is only by focusing on the smaller mistakes that we will be able to prevent the bigger mistakes.
By
Dr Sana Ansari
Manager QA, Clifton
Dr Ziauddin Hospital
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Reference:
https://news.yale.edu/2020/01/28/estimates-preventable-hospital-deaths-are-too-high-new-study-shows
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