How can we, while providing medical interventions, ensure our patient’s safety while reducing the opportunity for medical errors?

1.                  establish a procedure for dealing with medical errors

·        set up guidelines for implementing a root cause analysis

·        determine specific team members to comprise the RCA committee

·        establish criteria for factual information sharing

§         include the process of brainstorming, after information has been revealed 

·        establish criteria for problem solving

·        implement action plans for system corrections

·        evaluate effectiveness of monitoring techniques to ensure anticipated results are achieved

2.                  Increase organizational structure toward system responsiveness for medical error reduction

·        Simplify

     §         Decrease steps

§         Decrease number of people involved in each interaction

§         Increase training and education

·        Management support and involvement in all aspects of reducing medical errors        

  §         Decrease punitive actions (unless repeated mistakes)

§         Develop standard and non-routine processes through upper management

§         Develop emergency and non-routine processes through unit supervisory level to allow immediate response at site of occurrence 

·        Improve effective communication

§         Increase technology for computerization

§         Change to electronic signatures

§         Reduce opportunity for error or misunderstanding by implementing processes of clarity

·        Standardize

§         Practice Guidelines

-                     pneumonia

-                     acute MI

-                     Congestive Heart Failure (CHF)

-                     DVT prophylaxis

-                     Community Acquired Pneumonia;

§         Policies

-                     Specific policies to follow after certain procedures

-                     Address surgery

-                     Address ambulatory clinics

-                     Address ED

-                     What to do if certain events happen (bioterrorism,)

-                     integrate flow of information through system transfers continuum of care

·        increase technological support

·        Electronic MAR

·        Orders scanned for drug interaction, right patient, right dose, right time

·        Portable technology

·        Electronic Provider order management

·        provide evidence-based treatment

§         standards from national organizations

§         Professional journals available as resource to stay current

§         In-services to discuss and review standards of care

§         Work with those in research to effect positive change

Years of work by medical specialties resulted in recommendations for interventions that were founded on scientific evidence. The need to provide healthcare services that result in patient improvement based on referred and researched evidence-based knowledge has allowed all of our professions to evolve into the outcome oriented healthcare professions of today. Progress is demonstrated as new standards based on research are implemented to realize optimal outcomes. 

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