Large health care systems with multiple facilities can track as many as 1,000 events each month" (Berntsen, 2004, p. 44). That is an amazing number of cases that came extremely close to becoming medical errors, and they were only stopped by caregiver response or sometimes by chance. Near misses are an extremely important part of the healthcare facility's treatment program, because they can indicate just how accident and error-prone a facility is, and they can even indicate which departments and individuals may be the most error-prone.
How does a staff effectively reduce medical errors in their facility? Authors Turner and Kurtz believe debriefing of the team is key to reducing errors. They write, "Effective debriefing is the key to long-term sustainable improvements in patient safety and care. It is only through debriefing that an organization, team, or individual will improve consistently over time" (Turner, and Kurtz, 2008). Debriefing, the authors believe, should be confidential, non-threatening, structured and timely. They should take place as soon after the event or error as possible, and they should allow the participants to acknowledge their own errors or missteps, so they can identify them and improve them in the future. They should not be finger-pointing sessions or rants about safety. They should acknowledge what went well with the procedure, as well. Several studies indicate that a staff trained in debriefing is a safer and happier staff, with more effective patient outcomes (Turner, and Kurtz, 2008).
Debriefing is only one way to help improve or reduce medical errors. Communication is another key element, both between medical practitioners and other healthcare professionals, and between healthcare staff and patients. One reason errors occur is that healthcare prescriptions and orders have to go through so many channels, from doctor to nurse, to HMO, to lab or facility, to the operator, and on. Thus, a written order can be misconstrued at many different...
Patients need to understand their conditions and medications, and communicate about them if they see something wrong. Author Berntsen notes, "In health care a perception has developed in which substandard service and inefficiency are tolerated since consumers are not usually paying directly for care, even though they regularly make co-payments" (Berntsen, 2004, p. 178). In reality, patients are consumers, just as in any other area, but they often cannot change hospitals or doctors due to rude or shoddy service, because their HMO or insurance company will not allow it. It is up to these patients, then, to take charge of their own healthcare and ensure they are receiving the correct treatment, and it is up to them to report these conditions, as well. Patients have a responsibility to other patients to report problems so they do not occur again, and they have a responsibility to their own healthcare, too.
In conclusion, medical errors occur, they will always occur, and that means that staff needs to be constantly vigilant in order to manage and eliminate as many errors as possible. Good communication and teamwork can help reduce medical errors, and so can recognizing a team or individual's weakness. It is better to admit weakness and acknowledge there is a possibility of error, than to hide weakness and have a propensity for error. Healthcare workers need to know they are part of a team, and they need to work together, communicate effectively, and always be on the lookout for errors, so they do not occur as often as they might without worker vigilance.
References
Berntsen, K.J. (2004). The patient's guide to preventing medical errors. Westport, CT: Praeger.
Turner, S.H., and Kurtz, W.D. (2008). Debriefing for patient safety. Retrieved 28 Nov. 2008 from the Patient Safety & Quality Healthcare Web site: http://www.psqh.com/novdec08/debriefing.html.
