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Chapter 3 |
Chapter 4 |
Chapter 5
Chapter 6 |
Chapter 7 |
Chapter 8 |
Post test |
References
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Adverse Events and Near-Misses
When variances occur within a system, or when emergency situations occur, the need for immediate resolution is an absolute. In addition, there is a primary need to have the ability to implement reaction to emergencies at the level of the emergent occurrence.
The actual worker closest to the patient should have decision-making
options and the empowerment to take immediate action to prevent
sentinel events, or “near misses” that can result in medical errors.
System processes must be planned for through system integration. The
structure of an organization can be very rigid with strong administrative
over-seeing, but decision-making for reaction to emergencies must be placed at a
unit manager/staff level. This will allow for immediate responsiveness to
patient care issues of an emergent nature. This also allows for expeditious
reaction to situations such as census fluctuations for staffing rations.
Providing quick, decisive, and corrective resolutions, which decrease stress to
healthcare professionals, will bring about an atmosphere that promotes improved
outcomes with decreased medical error occurrences.
Areas of greatest complexity, intensity, and action must have tighter controls
to decrease the incidence for medical errors if patient safety is to be
improved. The emergency departments are a prime example of areas that incur a
tremendous risk for system breakdown. The better the system decreases the
potential for human error, the greater the decrease in medical errors.
Charles Perrow, an accident analyst, has studied many large incidents that
required investigation and answers to prevent reoccurrence. He states that
60-80% of accidents are caused by human error. That exemplifies the need to
increase technology, check and balance systems, and processes to help prevent
the ability for human error to occur. On the opposite aspect, the more
technology is present, the less able the worker will be to assist in the event
of a technological failure. This represents another example of a need for
policies and procedures, training and education, and system tracking to ensure
people stay current and knowledgeable in the event of emergencies.