Relationship Between Communication And Errors

The Healthcare field is becoming more aware of how important it is to change the way that organizational culture is becoming in order to help improve patient safety. Even though patient safety plays a very important part of our health care system which helps explain the importance quality of health care. However, when trying to keep patients safe, it can be a demanding challenge because of human errors and mistakes that are made. According to World Health Organization, patient safety is the absence of preventable harm to a patient while in the process of health care (who.int/patientsafety). Being in the position of a clinical content manager, the first step in reporting problems is to make sure that when reporting a problem, it need to be done at the earliest stage to show the importance to the company. The approach that I would take as a Clinical content manager is to identify the problem, have regular shift meetings to address any issues, flag any errors that occurred, have regular safety meeting, give feedback to staff on any errors that were found, try to figure out the best solution not only for the patients, but staff also, and although being a team leader, I would give the staff the opportunity to address any concerns that they may have.

The risk management program in any business, especially in a health care organization is an integral part of its day to day operation. The purpose of the risk management department is summed up by Kavaler & Alexander (2014), “…a program designed to reduce the incidence of preventable accidents and injuries to minimize the financial loss to the institution should any accident or injury occur” (p. 5). Protecting employees, patients, vendors and visitors is an ongoing process and one that needs to be updated when the healthcare organization has deemed necessary. This paper will demonstrate the importance of presenting the risk management program to new employees, compliance with the standards set forth by the American Society of Healthcare Risk Management (ASHRM), propose recommendations or changes needed to further improve the program, as well as examine the administrative process of managing a risk program.

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

Given the complexity of healthcare system today, effective and efficient collaboration and communication among team members is critical to ensure patient safety. Daniel & Rosentein (2008) reported that during a typical patient’s hospital stay, a patient may interact with 50 different employees that may include doctors, nurses, laboratory technicians, etc. They also reported that when healthcare professional are not communicating and collaborating effectively, patient safety is at risk for several reasons: break in communication flow, misinterpretation of information, incorrect telephone orders and overlooked orders.

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Patient safety is of major concern in healthcare settings due to the preventable nature of events that sometimes lead to serious injury, and even death, for patients. This was catapulted to the forefront of healthcare delivery in 1999 when the Institute of Medicine wrote a scathing report; To Err is Human: Building a Safer Health System, that highlighted "the lack of safety for patients in healthcare organizations" (Ulrich and Kear 2014). The National Patient Safety

Everyone in my company must comply with the health and safety procedure. We have to go on mandatory training to complete our health and safety certificate. This includes manual handling and fire safety. We must make sure our work environment is a safe as we can make it. If any accidents do occur i have to report them to my office or to the out of hours office, I must also record all accidents in the communication book so that other carers know what has happened this includes the nature of the accident, treatment received and where and when it happened. If any health and safety rules or procedures are breached then this may become a disciplinary for care staff. My line manager will always advise all care staff on and health and safety concerns that we may have.

Also enforced by OCR, the Patient Safety and Quality Improvement Act of 2005 (PSQIA) established a voluntary reporting system where data is analyzed and used to enhance the safety and quality of healthcare delivery. PSQIA provides confidentiality protections to healthcare providers who were previously concerned about the use of patient safety event reports in criminal, civil, and administrative proceedings. By limiting the use of event reports the fear report medical errors has decreased among many healthcare providers (Medical Errors and Patient Safety, 2008).

Finally, we must address accountability. We know hospitals, and long-term facilities can be a hectic work place and often face challenges of staffing issues and so forth. Nonetheless, we must be consistent. Godlock, Christiansen, and Feider (2016), recommends the use of a safety team in facility; some responsibilities may include identifying prevention strategies, education and teaching, spot checks, as well as patient chart reviews all of which promotes compliance and

An identification of the lines of responsibility and reporting for health and safety in the work place.

Bierly, Gallagher and Spender (2014) discuss multidisciplinary communication as a vital part of the growth of submarine programs into high reliability systems, providing a rich learning environment and the opportunity to receive information from a broad range of sources. This argument is also made for the healthcare environment by Miller, Riley and Davis (2009), Weaver et al (2013), Gillespie, Gwinner Chaboyer and Fairweather (2013) and Okuyama, Wagner, and Bijnen (2014). Bierly, Gallagher and Spender (2014) also identify that the structure of communication is important, including dedicated meeting times, with committed staff that combine individual authority into a powerful coalition, led by an advocate for safety. This advocate is then able to direct attention to issues that require follow up. Such briefings are recommended by McDowell and McComb (2014), Mills, Neily and Dunn (2008) and Bowie, Pope and Lough (2007). The issue of withholding, or non-reporting of, issues is identified by Bierly, Gallagher and Spender (2014). Bowie, Pope and Lough (2007) acknowledge that this has been an issue with incident reporting within healthcare systems; and the benefits of full reporting in a protected forum is advocated

“Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures” (Stavrianopoulos, 2012, pg, 202). Communication and teamwork go hand and hand. An effective teamwork involves effective communication. No communication can lead to possible medical errors, whether the failure to communicate comes from the patient to the nurse or between the health care providers. Evidence based care is another factor which aids in safety. “Healthcare organizations that demonstrate evidence-based best practices, including standardized processes, protocols, checklists, and guidelines, are considered to exhibit a culture of safety” (Stavrianopoulos, 2012, pg, 203). Providing better safety means learning from the past mistakes. By understanding the root of the issue, which would then lead to learning how to improve the situation. Educational training about safety should be available for medical staff to attend and learn if there was to be any doubt in he or she’s mind. Patient centered care is another factor in providing safety. It focuses on the patient and their family. Helping patient’s and family be more active in the care of the health plan can lead to safer and better

The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. “To Err is Human: Building a Safer Health System” released information that reported that tens of thousands of Americans were dying each year from errors (IOM, 1999). Patient safety moved to the forefront in healthcare like never before and directives were discussed to put quality as a

In 2000, the government released a report, via the AHRQ task force, called Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. This report was released

The concern with not educating trainees before graduation is that incident and near misses tend to remain underreported because of the perpetuating negative culture surrounding error reporting. This in turn hinders learning from the event and stifles growth toward voluntary sharing of broken processes and system failures (Barnsteiner, 2011). The current focus on Quality Improvement is to provide high reliable care with little to zero risks by including the “combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development” (IHI, 2015).