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 to 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 unfortunately preventable. But, it is clear that errors caused in healthcare thousands of deaths in the United States.
In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring. “Risk identification and reporting is a major tool used in risk management. ‘The values of reporting events, to learn what factors contribute to their occurrence, and to take actions to reduce or eliminate those factors are now recognized as key to improving patient safety’ (Shostek & Pronovost, 2006). Assuring a nonpunitive culture for risk reporting will foster an increase in risk identification” (Credo).
The same author stated: “Since the release of the 2001 Institute of Medicine Publication To Err Is Human, the word of risk management and patient safety has begun to coalesce and move to new prominence in health care. Identification of risk, development of corrective action plans, event disclosure, and providing apology to patients and their families are some of the responsibilities that risk managers undertake.”
Based on the patient safety, patient satisfaction, data, and culture of the institution, it is possible to choose different methods of reducing risk in health care settings. Those methods include ancient methods such flow-sheets, Kardex, sticker reminders, checklists. The EMR is a new and convenient method to mitigate error in health care settings. “’The use of reminder systems has long been suggested as a method of increasing clinicians’ adherence to guidelines’ (Ransom, Joshi, Nash & Ransom, 2011, p. 387). Over the year, flow-sheets, kardexes, sticker reminders, and checklists, among other things, have all been used to guide and remind us of care to provide and other obligations. Information technology and electronic medical records (EMR) promise to streamline these processes. There are a few institutions that are 100% paperless, but the truth is it will take many years, even decades, for many others to get there” (IHP 605 Module Nine Description, 2015).
I would choose three methods to mitigate error in health care settings: Just Culture; Electronic Medical Records; and Patient and Family Involvement in the Care.
I gave the following example in one of my posts: A nurse can; for example, make a mistake by giving an IV injection in IM. He or she should honestly report that mistake. In the concept of just culture; instead of blaming directly the nurse, an investigation process will be initiated to determine the real cause of the mistake. The mistake could be attributed to the negligence at any level; it could be attributed to a system failure. Then, the concept will fairly find out where the problem was and then, it will try to fix it.
Because errors are inherent to human’s nature; consequently, blaming or immediately terminating an employee involved in an error is not the right approach. Punitive approach is not effective. Instead, training and educational approach are the best way to handle adverse event based on the Just Culture concept. “In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety-related information” (American Nurses Association 2010).
About just culture, Joseph Pepe & Peter J. Cataldo 2011 said: “The concept of a fair and just culture refers to the way an organization handles safety issues. Human are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near-misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems – not to identify and punish the individual.” The same author stated that: “The moral imperative is to deliver the safest health care by taking account of human fallibility and the imperfections of the system.” The role of punitive sanction is persuasive. It can be implemented. But, it is not always effective. The threat and/or application of punitive sanction as a remedy of human error can sometimes help the system of safety efforts; but not all the time. It can even hurt the system sometimes.
Electronic Medical Records
Electronic Medical Record is a powerful tool that healthcare workers possess to improve the quality of patient care. It helps for diagnoses. It keeps the patient’s medical records in a safe place. That includes; but, not limited to patient’s medication, allergies, ROS, Physical Examination, Assessment, Order, and Treatment. EMR allows tracking the process of the patient care from check in to check out. Meaningful of EMR or EHR allows improving patient care. “Here again, the IOM did pioneering work, publishing, and subsequently revising a book on computer-based patient records, describing what would afterwards be more commonly referred to as electronic medical records (EMRs) and electronic health records (EHRs) as essential to both private and public sector objectives to transform healthcare delivery, enhance health, reduce costs, and strengthen the nation’s productivity” (Stephan P. Kudyba 2010).
EMRs or EHRs can help to reduce errors in healthcare settings by their meaningful use as defined by the CMS. “A qualify EHS not only keeps a record of a patient’s medication or allergies, it also automatically checks for problems whenever a new medication is prescribed and alerts the clinician to potential conflicts. Information gathered by a primary care provider and recorded in an EHR tells a clinician in the emergency department about a patient’s life-threatening allergy, and emergency staff can adjust care appropriately, even if the patient is unconscious. EHRs can expose potential safety problems when they occur, helping providers avoid more serious consequences for patients and leading to better patient outcomes. EHRs can help providers quickly and systematically identify and correct operational problems. In a paper-based setting, identifying such problems is much more difficult, and correcting them can take years” (HealthIT.gov).
Patient and Family Involvement in the Care
Patients and families can play an important role in healthcare delivery. Therefore, they must be involved in the process of the healthcare delivery. After every visit, patients and families should receive a copy of their medical records. They must know everything about their medical conditions and their medications. Patients and families must be informed about the benefits and the side effects of the medication taken. That approach contributes to reducing error in healthcare settings. Patients and families should be educated about their medical conditions.
Many studies showed that patients play an important role in preventing medical errors. “Observational data indicate that patients engage in a range of tasks that identify, prevent, and recover from medical errors in outpatient cancer care. The results of this study point to the importance of considering patients and their work in both the design of patient-care information systems and the structure of clinical-care environments that enable safe and effective health care” (Kenton T. Unruh, Wanda Pratt 2006). As aforementioned, patients must receive an electronic copy of their records, including problem list, medication information, labs results, allergies, and procedure information. They must receive the summary of each visit. That approach will help to prevent medical errors.
The root cause analysis is very important in healthcare settings. With the three methods aforementioned; the root cause analysis would allow us to determine the real cause of errors, and find out the ways to mitigate those errors from happening in the future. Error can happen in healthcare settings. But they must be appropriately addressed. According to World Health Organization; “Error is the failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning) (3). Errors may be errors of commission and usually reflect deficiencies in the system of care.”
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 unfortunately preventable. But, errors caused in healthcare thousands of deaths in the United States. Because errors are inherent to human’s nature; therefore, blaming or immediately terminating an employee involved in an error is not the right approach. Punitive approach is not effective. Instead, training and educational approach are the best way to handle adverse event based on the Just Culture concept.
I believe that Just Culture; Electronic Medical Records; and Patient and Family Involvement in the Care can help to mitigate error in healthcare settings. The Electronic Medical Records is a powerful tool that healthcare workers possess to improve the quality of patient care. It helps for diagnoses. It keeps the patient’s medical records. That includes but not limited to patient’s medications, allergies, ROS, Physical Examination, Assessment, Order, and Treatment. EMR allows tracking the process of the patient care from check in to check out. Meaningful of EMR or EHR allows improving patient care. Patients and families can play an important role in healthcare delivery. Therefore, they must be involved in the process of the healthcare delivery.
With the three methods aforementioned, the root cause analysis would allow us to determine the real cause of errors, and find out the ways to mitigate those errors from happening in the future.
FOOD FOR ALL (FFA); Let’s FEED FOR HOPE
Mohamed Elmahady CAMARA
ANA (2010): American Nurses Association: Position Statement: Just Culture; retrieved from
Credo: Risk Management in the Health Care Setting; retrieved from
IHP 605 Module Nine Description, 2015: How can informatics help prevent errors? Retrieved from
HealthIT.gov: Benefits of EHRs: Improved Diagnostic & Patient Outcomes: EHRs can reduce errors, improve patient safety, and support better patient outcomes; retrieved from
Kudyba S. P.: Healthcare Informatics: Improving Efficiency and Productivity: Quality Time in Healthcare: Strategy for Achieving National Goals for Meaningful Use of Health Information Technology: Drivers of Change to Promote a More Productive Industry: Chapter: 2, Page: 23.
Pepe J., Cataldo P. J. (2011): Manage Risk Build a Just Culture; retrieved from
Unruh K. T., Pratt W.: Patients as actors: The patient’s role in detecting, preventing, and
recovering from medical errors; retrieved from
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adverse event reporting and learning systems: From information to action: Definition;