The quality and safety standards are key features in health care which needs critical considerations. Quality should be patient centered through safe, efficient and timely operations which are a core factor for nurse leaders. They should understand organizational dynamics to enable better integration and implementation of certain changes in the health care. The leaders should encourage cooperation and team building among the junior nurses so as promote their safety and quality standards.
The leaders should develop strategies which are visible on the clinical units which support quality standards so that other nurses can implement them. Effective communication and sharing of vision of excellence among junior nurses promote the services offered to the patients. The leaders should partner with quality to improve the culture of providing quality services in the entire nursing institution. Nurse leaders should role model excellence to bring teams into alignment which will bring positive outcomes to the patients, groups and also the organization.
Diagnostic errors are some of the common medication errors in health care systems. It, however, has received less attention despite being dangerous to the lives of the patients. A study by Harvard Medical Practice found that it accounts for 17% of preventable errors 9% of patients experienced undetected diagnostic errors over the last four decades (MacDonald, 2011). The main cause of diagnostic errors involves diagnosing a current patient based on experience with past cases. Other causes are relying on initial diagnostic impression, making unduly bias during diagnostic decision and placing undue reliance on test results.
To prevent the errors, proper systems which mitigate effects of biases should be implemented to provide physicians with information for decision making. Regular feedbacks to clinicians on diagnostic performance will help eradicate the errors. Information technology and teaching clinicians and trainees about fundamental parts of cognitive psychology are necessary to reduce diagnostic errors (Agency for Healthcare Research and Quality, 2017).
The Costs of Poor Quality and Unsafe Practices from Diagnostic Errors
The diagnostic errors cause injuries, infections and adverse health problems which might lead to the death of the patients. Unsafe injection practices can cause complete or partial paralysis of the body of the patient while using unsafe blood products may cause infections of chronic diseases like HIV/AIDS (Agency for Healthcare Research and Quality, 2017). The diagnostic errors cause further suffering of the patients and costly inconveniences which include financial burden.
A classic case of diagnostic error occurred in 2014 where an obese patient with asthma and on oral contraceptives controversially died due to medical errors. The patient was treated with skin problems and given antibiotics which led to shortness of breath and rapid heart rate. The patient passed away in a short time due to pulmonary thromboembolism (MacDonald, 2011). Near event are adverse events which are serious to live of patients but are preventable while near miss is mostly medications which do little or no harm to the patients and are somehow beneficial.
Cause Analysis (RCA) And The Purpose Of Using RCA.
Rot because analysis involves mechanisms, approaches, and techniques used to determine the cause of a problem. The analysis aims at removing a primary factor which will stop the undesirable event from happening again. Focusing the correction on cause after an event has occurred and is its insights is useful because it is a preemptive method (Dunn, 2006). The RCA can be used to predict future events before they occur thus helping to apply the appropriate technique to solve the specific problem.
Factors That Create a Culture of Safety.
Visibility of the leadership and staff is the main culture which promotes patients safety. The leaders can convey their commitment to each other regularly through meetings and make the patients safety their main agenda. Staff members should ensure implement boardroom policies in patient care units and work with executive leadership to improve patients safety. Vision is another factor driving the culture of safety. The healthcare leaders should create vision through analyzing to determine the current level of the organization regarding safety and way forward (Smith & Wadsworth, 2009).
The commitment of medical officers and leadership through the consistent promotion of safety education programs and proper handling of medical errors. God team structure in hospital units is another factor that improves safety culture through the willingness of staff members to support each other. They courageously stop each other if they dont exercise patient safety. Lastly, accountability promotes a culture of safety and builds comfort levels among different levels of staff to jointly discuss how to improve patient safety (Smith & Wadsworth, 2009).
The culture of safety is seen to be beneficial in improving the quality of the medication offered to patients. Doing medical procedures and properly diagnosing patients leads to low death cases caused by poor safety standards. The constant teaching of medical staff about medical safety standards is fundamental in improving their culture of safety. Recently, cases of patient neglect and rise of medical errors have been reported in many hospitals. This shows the safety of patients is not taken care of thus proper mechanism should be adopted to correct the situation.
Agency for Healthcare Research and Quality. (2017). Diagnostic Errors | AHRQ Patient Safety Network. Psnet.ahrq.gov. Retrieved 25 July 2017, from https://psnet.ahrq.gov/primers/primer/12/diagnostic-errors
Dunn, S. (2006). Getting Root Cause Analysis to work for you. Maintenance and Asset Management, 21(3), 26.
MacDonald, O. W. (2011). Physician perspectives on preventing diagnostic errors. Waltham, MA: Quantia MD.
Smith, A. P., & Wadsworth, E. J. (2009). Safety culture, advice, and performance. Report submitted to the IOSH Research Committee. Cardiff University.
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