Factors that impact medical errors
- A medical plan that doesn't work
- The wrong plan could be used.
- Flaws in the way the system is organized
- Limited human resources of time, energy and manpower
- Poor communication
Power issues
- Limited financial and human resources contribute to a stressful work situation that is error-prone.
- Healthcare professionals can feel powerless to challenge physicians, or anyone with more power.
- We can only be part of the solution when we have the power and ability to respond and speak up when a situation needs changing.
- We lose power when we believe in inequality.
- We lose power when we believe that it is our responsibility to make another person (like the doctor ) happy.
- We lose power when we judge ourselves and others against unrealistic standards.
- Power comes from knowing who you are, valuing who you are as important, and staying centered in your value.
- We need our own power before we can empower our patients to act as their own monitors of the care they receive.
- We need power to change the systems that we work in.
- Power dynamics are factors in the occurrence of medical errors.
Communication with Doctors
- Indicate you want to speak
- When you speak do so in the first person
- Give what you say appropriate strength of feeling
- Persist if someone cuts you off
Communication with Patients
- Without patient involvement in decision-making, there is a higher rate of noncompliance, which can lead to ineffective treatment- an error
- The patient can be a powerful ally in monitoring for untoward effects
- They can provide feedback necessary for treatment
- Communication can be one of our more powerful way to reduce medical errors
Other staff factors
- Fatigue
- Substance abuse
- Illness
- Distraction
- Emotional states
- Equipment design flaws
- Inadequate or inappropriate labeling
- Inadequate or inappropriate instructions
Medical errors tend to be system errors, and we are all part of this healthcare system.
Recognition of Error-prone situations
- Medication, (physician order, pharmacy dispensing, administration of medication)
- Surgery ( amputation of wrong limb)
- Diagnosis
- Equipment failure
- Infections (nosocomial infections- picked up because of contact with the healthcare environment)
- Blood transfusions
- Misinterpretation of medical orders
- Errors of omission
Studies of errors
Medical studies have shown that the majority of medical errors are preventable.
