To Err is Human - Essay PDF

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To Err is Human: Creating Safety Systems in Health Care Organizations Quality and Safety in Nursing NUR 2833 Keiser University October 10, 2019

TO ERR IS HUMAN 2 Creating Safety Systems in Healthcare Organizations “Safety is a characteristic of systems and not of their components. Safety is an emergent property of systems.” The eighth chapter in the book To Err is Human, is mainly concerned with the creation of safe systems within healthcare organizations. While recognizing that there are several systems already in place to prevent and or mitigate damage or injury due to mistakes, this chapter also spells out different ways that healthcare professionals, on all levels, can design safer systems that would manifest in a safer work environment for healthcare workers, and a safer environment for patients as well. During the process of finding and outlining issues within systems in the healthcare industry, systems in several other industries were studied as well. Those involved with this study took examples from many different companies that have dangerous manufacturing processes and studied how they were able to reduce if not eradicate the loss of work hours due to injury. After much examination it was found that, by far, the most damaging factor to the overall advancement of patient safety is the frequency with which medical errors occur, and the surprisingly small amount of attention paid to them[ CITATION Koh00 \l 4105 ]. This intensive research on the functionality of safety systems in a multitude of industries led researchers to a list of five principles that were found to be most important if the goal of vastly decreasing or eliminating errors in the healthcare industry was to be achieved. These principles are: 1. Providing Leadership Those in leadership positions are constantly looking for ways to enhance efficiency and productivity. While attempting to achieve these higher standards,

TO ERR IS HUMAN 3 providing the absolute best level of care to all clients must be made a priority. Quality of care and patient safety should never be threatened by a rush to efficiency[ CITATION Jan17 \l 4105 ]. Additionally, creating nonpunitive environments within organizations would go a long way towards fostering an atmosphere of trust and understanding between healthcare workers and their management teams. Once this trust is established, there would be less apprehension surrounding the reporting of employee errors, allowing for a faster response and a prevention of adverse outcomes. While creating this nonpunitive environment for employees to report possible errors on their part, it must be recognized that there must be effective methods of distinguishing accidents from malfeasance or incompetence, and appropriate consequences in place once these circumstances have been discovered. 2. Respect for Human Limits in Process Design Essentially, this point outlines the need for the understanding of the underlying causes, or pathophysiology of errors, to fully understand how to treat or avoid them at all[ CITATION Koh00 \l 4105 ]. While acknowledging that the majority of accidents are the result of human error, it must also be recognized that these errors are usually the fault of flawed systems that have been put in place. Often times these systems do not take into account the weaknesses inherent in the human animal. Two of these potential conflict points is the reliance on memory or vigilance. Given the long hours worked and stressful situations that healthcare workers routinely find themselves in, it is easy to see how relying on memory and vigilance could become a potential risk to the proper functioning of safety systems. In the process of creating safety systems in healthcare, it is essential to

TO ERR IS HUMAN 4 recognize the capacity of these systems in the reduction of errors[ CITATION OuA17 \l 4105 ]. 3. Promote Effective Team Functioning It has been shown, on many occasions, that the team centered approach to healthcare is superior to healthcare workers “going it alone”...