Smetzer System Failures

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

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 .

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

This documentary video is very informative and very useful as eye-opener to all that works in the healthcare industry. John Hopkins patient safety expert have calculated that more than 250,000 deaths per year are due to medical error in the U.S. This large number, victims of medical error, leads to a stigma that people became questioning and doubting the capabilities of healthcare providers resulting on losing trust. This video “Chasing Zero” is a reminder that all nurses, doctors and all the people that works in healthcare industries should be very cautious on the care they provide to patients. A single error can hurt and worst, it can kill someone. This video made me realize as a nurse, that anyone can make a big mistake regardless of years

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

November, 1999 brought about a release of a report prepared by the prestigious National Academy of Science’s Institute of Medicine (IOM) making medical mistakes and their magnitude of the risks to patients receiving hospital care to common public knowledge. The IOM concluded that between 44,000-98,000 deaths occur annually because of medical errors. Among a general agreement was that system deficiencies were the most important factor in the problem and not incompetent or negligent physicians and other caregivers (Sultz & Young, 2010). An excellent example of a system deficiency that leads to a crisis and sentinel event was the highly publicized overdose of Heparin to Dennis Quaid’s newborn twins in 2007.

It is the goal of all healthcare providers and organizations to provide quality care to all patients without error. The truth is, even healthcare providers make some mistakes. The question is, when an error occurs who is to be held responsible? Is it, the nurse who administered the wrong medication, due to being overworked and lack of staff to help? Or is it the Healthcare Organization (HCO), because they should have fixed the staffing issues. There are so many factors that contribute to an error. I believe each situation should be properly investigated, before placing blame where it should or should not be placed.

One of the standards that has been implemented is Standard 4: Medication Safety. The Australian Commission implemented this standard with the intention of ensuring that competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and monitor the effect. (Australian Commission on Safety and Quality in Health Care, 2012) In healthcare, one of the most common treatments is medication. As a result of this, there are many incidences of error, many more than any other healthcare interventions. According to the Patient Safety Network (PS Network, 2015) medication errors account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Medication errors are often a result of the unsafe and poor quality practice of healthcare professionals or system errors. Medication errors are costly and many are avoidable. For this standard

The National Patient Safety Goals were created in response to the IOM article, To Err is Human: Building Safer Health Systems. These goals were written to address patient safety and are tailored depending on the health care setting to which they are written for. They address system wide solutions rather than focusing on whom or how the error was made. Medical errors have been noted as being the 8th leading cause of death in the U.S. with the most frequent of these errors being medication related (Johnson, K., Bryant, C., Jenkins, M., Hiteshew, C., & Sobol, K. 2010). Therefore a great focus on these goals is needed across the health care continuum. The goals are updated and amended on a regular basis using evidence-based research, in response to areas with high errors in patient safety.

It is critical in today’s health care field to avoid harm and ensure that patient safety in health care environment, especially with the attention of medical mistakes little is known about the importance of avoidable harm to public. The mistakes that happen in the healthcare setting are rarely the fault of individual workers, but usually the result of problems within the system that they work.

“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 third leading cause of death in America may surprise you. Hospitals and healthcare organizations dedicate their branding to reflect a place of hope, comfort, and healing when ones health is compromised. Sadly, medical errors do exists in the realm of healthcare. The National Center for Biotechnology Information defines medical error as “an act of omission or commission in planning or execution that contributes to or could contribute to an unintended result.” Medical errors may include incorrect record keeping, administering incorrect medication to a patient, misdiagnosis, failing to remove all surgical instruments and performing surgery on the incorrect site. The Agency for Healthcare Research and Quality identified eight factors that contribute to the cause of medical errors. These factors include “communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns, technical failures and inadequate policies and procedures.”

If not, they should be shown of the patient safety issue and what and how the cost is affecting the facility. Administrators and management can be shown percentages of each floor and the number of patients that have been affected by medication errors, increased stay at the facility, and how and what medication was issued. The administrators and management can be given a presentation by PowerPoint and researched documents about the medication errors and how it has helped other facilities nationwide and possible cost of the savings to the facility for implementation. The barriers would be cost of materials, timing of transition, staffing needs for training and medical staff unwilling for change in the facility. With medication errors on the rise, patient’s safety at hand, and cost of saving the facility money on preventative measures, the administrators should lean towards the

In 1966, a Spanish couple welcomed a new baby to the world in a Denver hospital. Because the couple only spoke Spanish, communication between the couple and the healthcare staff was impaired. The mother had a history of syphilis, and it was difficult for the hospital to understand how the mother had been treated for this disease. After discussion between employees, a decision was made to treat their newborn for congenital syphilis and an order was written for Benzathine penicillin G 150,000U IM. The hospital pharmacist read the order incorrectly, mistaking the “U” for a zero making the order 1,500,000 units. The nurse caring for the baby expressed concern about injecting a high amount intramuscularly as the label on the bag instructed. Further discussion took place between staff, and a decision was made to administer the medication intravenously (IV) instead. The IV administration resulted in the death of the infant died. An autopsy later revealed that the baby did not have congenital syphilis, and therefore no treatment was truly needed (Aspden, 2007, p.43-44). Medication errors can be deadly as the previous example shows. A medication error is defined as, “any preventable event that may cause or lead to inappropriate medication use or patient harm while

The ultimate example of degeneration, however, is Smerdyakov. With a mother who did not have the mental capacity to even speak, and a father who more than likely took advantage of such an impairment, Smerdyakov had little hope. Besides his epilepsy, Smerdyakov had Fyodor’s vanity, arrogance, and the ability to play the ultimate fool. What provides evidence for the degeneration theory, though, is Smerdyakov’s capability of committing murder and allowing another to take the blame. There was no purpose for murdering Fyodor as Smerdyakov did, no guilt for taking a life or ruining another, no conscience or moral compass; the ultimate degeneration of a person’s morality.