Threat To Quality Health Care Essay

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1. Recognizing that health care errors affect at least one in every 10 patients around the world, the World Health Organization’s World Alliance for Patient Safety and the Collaborating Centre identified priority program areas related to patient safety. What are the patient safety program areas the nurse manager should consider for implementation?

2. Describe the Joint Commission 2017 National Patient Safety Goals for Hospitals.

3. Discuss the Institute of Medicine’s four-pronged approach to reducing medical mistakes?

Patient safety has always been the heart of healthcare practice and nursing through the history of medicine. However, all through the world occasional non-deliberate accidental harm occurs to patients looking for care. Such unfavourable incidents can occur at all levels of healthcare whether clinical or managerial, curative or preventive, and in general healthcare, or private. It may occur at any stage of management (radiology, laboratory, operating room, ward, or ICU).Threat To Quality Health Care Essay

The WHO, at the meeting held on July 2006, in New Delhi, India, identified an adverse event as a separate unconnected incident associated with health care, which results in in-deliberate injury, illness, or death. Such incidents can be preventable as with contaminated injections.

Published surveys on patient safety show that in industrialized advanced countries, more than half of these adverse events are preventable and occur because of a shortage in system or organization design or operation rather than because of poor performance of healthcare providing staff (WHO report, 2006).

Harvard Medical Centre study in 1991 (after WHO report, 2006) was the first to draw the attention to the volume of patient safety problem. Based on medical records review, the rate of adverse event in three US medical centres ranged between 3.2 to 5.4 percent. In UK, the rate was 11.7 percent and in Denmark, the rate was 9 percent (WHO report, 2002). Results of recent studies suggest the rate is between 3.2 and 16.6 percent (per 100 hospital admissions). The situation in the less well-documented health care centres in the developing countries is more serious (WHO report, 2006).Threat To Quality Health Care Essay

The cost of adverse events that endanger patient safety can be very high, considering all the aspects. It includes, loss of confidence and credibility and reputation of health care institutions, loss of enthusiasm and job gratification among the working staff. In addition, the cost includes damage to the patients and their relatives especially when taking defensive attitudes and keeping information hidden from patient’s families. Other added costs are those of prolonged hospital stay and increased medical expenses and those of lawsuit demands (WHO report, 2006).

Objective
The objective of this paper is to review, in brief, the problem of patient safety with particular attention to patient safety in the ICU being one of the essential patient care systems in a health care organization. Besides, the vulnerability of ICU patients augments the importance of patient safety concept.

Methodology
This thesis is a literature review study. The researcher performed an article search using the following internet databases:

National Centre for Biotechnology – National Library of Medicine – National Institutes for Health (NCBI), at http://www.ncbi.nlm.nih.gov
Medscape database, at http://www.medscape.com
Amedeo: The Medical Literature Guide, at http://www.amedeo.com
British Medical Journals, at http://group.bml.com/products/journals
World health organization – Publications, at http://www.who.int/en/publications
Yahoo and Google scholar general databases, site of .org, .gov and.edu only considered.
Terms of search were patient safety, basics, and principles of patient safety, review of patient safety, patient safety in the ICU and the critically ill patient safety.Threat To Quality Health Care Essay

Findings
Patient safety event is a wide term; it does not only mean a medical error during the course of medical management and nursing. The Department of Health and Human Services, 2008, defined a patient safety event as an incident, which takes place during providing a health care service.

It causes or may have caused a harmful outcome to the patient. It includes errors of not doing (omission) or errors of doing (commission), it also includes faults and mistakes of the patient care processes (involving drugs and equipment’s) or the environment where these processes are carried out.

The phrase, one cannot manage what cannot be measured hold true for patient safety. One of the reasons of the lack of effective patient safety strategies is the need for a measurement tool to provide measures, consequently, reduce medical errors and improve patient safety.

The Agency for Healthcare Research and Quality (AHRQ) developed an array of Patient Safety Indicators planned to screen administrative data for events related to patient safety. This list of indicators includes 16 situations where a threat to patient safety may occur during the course of healthcare delivery. Using this measurement tool shows that patient safety incident of highest rates are failure to rescue, decubitus ulcers and postoperative wound infection (which is specifically increased by 35% during the period 2002-2006) (Health Grades Inc, 2006).Threat To Quality Health Care Essay

Infection control: An important part of patient safety
Bruke, 2006, has provided a comprehensive review of infection control as an important aspect in patient safety strategy. Based on many studies, hospital acquired infection; in this context, alternatively called health care associated infection, is one the most frequent risks for patient safety in patients admitted to hospitals. The answer to the question of why it is an important aspect for patient safety lies in the fact that 5-10 percent of patients admitted to acute care hospitals acquire one or more nosocomial infection. In the US, 2 million patients acquire hospital infection every year with 90.000 deaths.Threat To Quality Health Care Essay

This adds a cost of 4.5 to 5.7 billion US $ to the health care cost (Bruke, 2006). There are four types of hospital-acquired infections, which account for 80% of the total rate. These are infection associated with urinary catheterization, blood borne infection (usually with vascular invasive procedures), surgical wounds infections, and pneumonia (usually associated with the use of ventilators). Therefore, it is understandable that 25 per cent of these infections occur in the ICU (Bruke, 2006).

The increased awareness of patient safety resulted in reorganizing the concepts of infection control and placing it in the domain of public health with consequent increased surveillance and epidemiological studies. It is true that recognizing risk factors allows clarification of what is adjustable and what is not, however modification of some terms is advisable. Instead of saying avoiding the use of catheters, we should recommend reducing the duration of use of catheters. Many other terms as use antibiotics intelligently, and training and staff education are hazy and indistinct, accordingly, tricky to employ (Bruke, 2006).Threat To Quality Health Care Essay

Nursing practice and patient safety
The report of the Institute of Medicine, 2004 (after Armstrong and Laschinger, 2006) recognized nursing role as pivotal to patient safety. The report suggests the degree of activity of hospital nurses and the extent of giving them authority to take part in decisions, directly affects the quality and perception of patient safety. The results of Armstrong and Laschinger, 2006 supported this assumption; they recommended that nurses should enjoy better communication and participation in decision-making. The responsibility of nurse managers, at the unit level, is even greater.

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They take part to establish nursing practices, which support patient safety culture, they also sustain professional nursing practices, and they should listen carefully to nurses relevant affairs. If nursing managers achieve their direct responsibilities, then they work with others in the healthcare establishment to make the organizational process better as regards limiting the nurse’s competence towards better patient care. The result of Armstrong and Laschinger, 2006 suggested that nurse managers (nurse leaders) have the capability of developing patient safety in healthcare organizations.Threat To Quality Health Care Essay

Medication management and patient safety
Duthie and colleagues, 2004, analyzed the 108 reports submitted to the New York State Department of Health investigating the medical errors in New York State healthcare organizations. From quantitative viewpoint, their results suggested that nursing the first discipline to be involved in such errors and they provided the explanation that nurses are the end dispenser since they give the medications to patients directly.

In addition, they showed that patients over 65 years are the most vulnerable to these errors, perhaps because of the increased number of medications prescribed at this age. From a qualitative viewpoint, they suggested that what may endanger patient safety is dispensing system malfunction, failure to rescue situations and working space limitations. They suggested the need to educational initiatives and pointing out possible dispensing system malfunctions.

Adamski, 2005, suggested the following precautions to minimize medication errors:

Monitoring how patients respond to medications as long as it is dispensed in the healthcare organization.
Diagnosis and indication for a particular medication should be available in the patient’s progress notes, history or examination sheets.Threat To Quality Health Care Essay
Clear order forms to dispense medications in order to ensure clear and mutual understanding among the prescribing physician, pharmacist, and thenurse who administers the medication.
Davis and colleagues, 2006, examined the patient role in medication errors. They suggested that low literacy patients (up to 6th grade level) are more liable to misunderstand medications label instructions. However, they suggested that lower reading and writing skills and high number of medications prescriptions link separately to misunderstanding of instructions on medications labels.

Hospital design and device purchase in patient safety strategies
Reiling, 2005, suggested that building a hospital (whether new or relocated) around the principles of patient safety would have two important impacts on return of investment. First, it combines safety and efficiency, second, it reduces the costs of adverse effect and hospital stay therefore; reduces the patient’s cost on discharge.

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To achieve a safety cantered hospital design, Reiling, 2005, suggested that architects, engineers, contractors, heads of departments and executive managers should participate in discussions around what they need. There is no specific design but contributions of the whole team from the perspectives of patient safety culture are mandatory.Threat To Quality Health Care Essay

Johnson and colleagues, 2004, examined the patient safety in purchasing equipment. They analysed purchasing decisions taken at three different healthcare centres. Johnson and other, 2004, assumed there were points of strengths and others of weaknesses. The points of weaknesses draw the attention to the necessity of having guidelines to help healthcare providers to assess issues of patient safety when purchasing medical devices.

Patient safety in the ICU
There are many reasons that make the ICU a special unit to look at specifically as regards patient safety. Of these reason, the patients are critically ill, which renders them vulnerable to the adverse effect of medical errors. Second, the great effort performed by nurses and internists with sometimes exhaustive shift work, which may result in sleep deprivation and possibly lack of concentration.Threat To Quality Health Care Essay

Third, the diverse use of equipment (ventilators, catheters, monitors etc) and the invasive procedures sometimes adopted (emergency tracheotomy, central venous pressure or arterial-venous cannulation) which add to the risk of hospital-acquired infection or increase the incidence of adverse effects (Rothschild and others, 2005).

Rothschild and colleagues, 2005 conducted a one-year prospective observation study as a part of Harvard Hours and Health Study (2002-2003). They designed their study as a multidisciplinary epidemiological study to portray both frequency and types of adverse effects in the ICU. The result were informative, there were 120 adverse events reported (80.5 per 1000 patient-day). Of the patients who suffered adverse effects, 13.8% suffered one adverse effect, and there were 16 life-threatening adverse effects.

The commonest were respiratory, infection, and cardiovascular system (19%, 15%, and 12% respectively). The incidence of serious medical errors was 149.7 per 1000 patient-day of which, 11% were life threatening. Incident discovery was by direct observation in 62% of the cases and the patient’s nurses discovered 36 % of the cases. In 74.8% of cases, errors occurred during the course of treatment or a procedure.Threat To Quality Health Care Essay

An intern failure to wash hands after attending a patient formed 51% of sterility hazards related to procedures. Although their results cannot be applied to all ICU units, yet it draws the attention to how frequent and how serious patient safety can be compromised in ICU units. At the same time, their result show how results of treatment in the ICU would improve, despite the hard work, if teams stick to unit protocols and principle of patient safety (Rothschild and others, 2005).

Kho and others, 2005, used the Safety Climate Survey (a tool approved by the Institute of Health Care Improvement) to measure patient safety in four ICU units, 56.9% of those responded to the survey were nurses. Based on their results, they assumed that Safety climate survey and Safety culture scales are reliable tools to measure patient safety in ICU.Threat To Quality Health Care Essay

Chang and other, 2005, suggest that reform of patient safety in the ICU should start by establishing physician and nurse leadership, once this is achieved, carrying out patient safety protocols becomes a matter of team effort and commitment to the concept. Identifying a specific group of patients to start with (as an example, patients on ventilators), planning carefully the procedures, and opening a communication channel among the staff should reach the best results.

Following evaluation of what progress made, the next move is for another group of patients. At the end, this should provide synchronization among the staff that makes decision making in shortage of time easier and provides better training and education to the newly coming staff.Threat To Quality Health Care Essay

Obstacles facing the implementation of patient safety
Cook and colleagues, 2000, considered the complexity of healthcare as an overwhelming obstacle to achieve desired patient safety levels. Technical work in healthcare needs appropriate and quick decision making, critical to the patient’s safety at times, moreover, it is risky by nature. It is true that health practitioners whether physicians, nurse, technicians or other staff are trying to cope with this complexity, however this complexity creates a disparity in healthcare practice and nursing (they called it gap).

Cook and colleagues assumed the means of improving patient safety is by supporting practitioner’s ability to perceive and cross these disparities, rather than making changes in authority or different roles with possible division of professional work force. The search and detection of these disparities or gaps as a research goal should make the breakthrough in patient safety achievements. During this research pursuit, disparities indicate areas of weaknesses and susceptibility and may elicit the means complexity flows through health care systems to patients (Cook and colleagues, 2000).Threat To Quality Health Care Essay

Amalberti and colleagues, 2005, identified five system barriers to even safer healthcare; the first is regulations, which significantly limit the risk allowed, thus, limiting maximum performance of healthcare givers. There is a real need for proper balance between the industrial notions to get a high productivity whatever it takes, and the concepts of patient safety culture. Doing that, researchers should take into consideration the economic troubles of the healthcare system and the spontaneous drive of productivity among healthcare workers.

Second, other important issues need dealing with before or in conjunction with the issue of patient safety, an important example to these issues is the need for standardization of healthcare practice and nursing. Third, the core of healthcare work is synchronization among practitioners, therefore recommendations should stress on teamwork and opening communication channels among the healthcare staff, instead of trying to reach optimal performance of each organizational level separately. The fourth obstacle is the need for system-level mediation to improve patient safety planning.Threat To Quality Health Care Essay

According to World Health Organisation (2010) Patient safety is the prevention and avoidance of adverse circumstances or injuries coming from health care process. Accidents, errors are common events that can occur in the clinical area. Safety arises from the interaction from different parts of the system: it does not live in a person, department or device. Patient safety is a branch of health care quality.

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Patient safety could be defined as the prevention of errors and adverse effect associated with patients in health care. Health care has become more complex and more effective with greater use of medicines, treatment and more use of technologies; also, patient safety is the prevention of adverse effects to patients and prevention of errors associated with health care. In every care given there is a certain degree of unsafe practice, wrong procedure, side effects of drugs, hazards done by a faulty or substandard medical device used in the health system, human errors or system errors (latent) failures (World Health Organization, 2002).Threat To Quality Health Care Essay

Patient safety is a global issue whereby about 2.3% -16.6% adverse event rates have been documented from acute care hospitals. 1.4 million people worldwide have also been reported by the World Alliance for patient safety are suffering from acquired infections from hospitals and in the developed world 10% of patients admitted to modern medical hospitals acquire one or more infections.

In Africa and Asia pacific region, patient safety is a very big issue of concern. In the developing countries the risk of health care associated infection is 2-20times higher than in developed countries, sometimes the percentage of health care acquired infection can exceed 25%. The countries rise of unsafe care is alarming (WHO, 2007, pp. 15).

Nursing literature and standards of professional conduct elevating patient safety and standard care all presuppose the importance of excellence in nursing practice. About what excellence is and how it may be operationalised as a moral essential in patient safety discourse is not well interpreted. It may not be possible to effect to any one specific definition of the idea what excellence in health and nursing care area is, but only to give examples of distinct excellences of professional practice and professional lives for example case of exceptional caring, exceeding honesty, outstanding understanding and skill, laudable wisdom, uncommon patience and eminent integrity.Threat To Quality Health Care Essay

RISK ASSESSMENT
It is the identification of attendant uncertainties in order to estimate the risk in an organization IPCS (2004). Risk assessment is the first constituent in risk analysis process which also includes management of risk and communication of risk. Risk assessment refers to techniques and methods that apply to the judgment of hazards. Risk assessment starts with problem formulation which includes four additional steps as elaborated below:

(1)Identification of hazards;

(2)Characterization of hazards;

(3)Assessment exposure;

(4)Characterization of risk (IPCS, 2004).

Identification of hazards entails recognizing the hazard and acting fast to prevent an incident from occurring. Characterization of hazards has to do with the drug, object or procedure that might cause the adverse effect. Assessment exposure involves how are patient expose to this hazards, how much danger is likely to occur, how long is the danger likely to occur, what measure of danger is appropriate for typifying health risk? Characterization of risk involves how does the assess exposure compare guidance value for the drug?Threat To Quality Health Care Essay

The nurses on duty in this case scenario did not act as harm absorbers by ensuring the safety of the young girl in the ward by combining expertise, experience and training which is required from experienced nurses. They needed mental alertness or foresight to identify on time that the patient tourniquet was not unfastened.
National Patient Safety Agency (2008) has developed a mental preparedness training program which aims at enabling nurses to increase knowledge of determinant that raises the chance of patient safety incidents, boost their confidence to keep patient safety incident from happening and understanding risk-prone situations better. Reason (2004) cultivated a method for analysing risks which was structured around the three-bucket model. According to the model, most patient safety incidents can be prevented if clinical staffs foresee error before any task, procedure or action is attempted. The assessment is divided into three parts, which are: the self-bucket, context-bucket and the task-bucket. Relating these three-bucket prediction approaches to the case scenario examined in this essay is detailed below.Threat To Quality Health Care Essay

In the self-bucket, the registered nurse that collected the blood sample from the little girl had a low level of competence and experience because it is the duty of a medical laboratory scientist which she is not. She was not aware of the policies that governs the procedure and never took her time to cross-check what she was doing.

In the context-buck the registered nurse on duty lacked team support from her colleagues. The four registered nurses on duty would have shared the patients in the ward to themselves in a ratio of 10:1 and the unfastened tourniquet would have been noticed by the staff nurse in charge of this young girl.

In the Task-bucket the registered nurse that collected the blood sample was unfamiliar with the task so did not remember to unfasten the tourniquet. She would have asked for a medical laboratory scientist who has more experience in this procedure and it would have help reduced the work load for this staff nurse because the ward was busy and full.Threat To Quality Health Care Essay

Reason (2004) noted that using foresight is a fundamental skill of an experienced registered nurse and for it to be more effective it must be practised. He goes on to say that healthcare professionals who needs to develop error wisdom, alertness and quick reactions needs to apply it, should use the simple three-bucket model of error which might help them the foresight factors that raises the chance of patient safety incidents. Training on risk assessment does not have to take place in classroom but can be cultivated in forming part of clinical handovers, or of daily training programmes involving for example, manual handling and lifting which was not done by the nurses on duty in this scenario.

The training programme designed created to equip staff with prospective risk assessment abilities and a simple model needed for use in their everyday work. It aim is to help nurses to do something to prevent incidents, improve nurses knowledge of the factors that can be added to make patient safety incident occur, educating nurses by encouraging them to share their experiences of patient safety incidents, improving their knowledge of risky situations.Threat To Quality Health Care Essay

The program also help prepare staff nurses to undertake urgent risk assessments of risky situations by encouraging them to accept that errors can and will always occur and to be more at alert of safety gaps where they work, know how to check situations before starting a task and so increases chances to minimise and avoid errors and to note and anticipate problems and to prepare in advance to deal with them. Ask for more qualified help when necessary and to know what stops them from asking for help.

THE SCENERIO
My patient case scenario happened in south — south Nigeria, West Africa where a student nurse did her clinical practice. An eight year old girl who was admitted for the treatment for malaria had her arm amputated before discharge from the hospital. This young baby as I will call her was admitted into a 40 bedded busy ward with just three trained registered nurses on duty on each shift. She came in with severe pyrexia which was later brought down, but on the third day of her stay in the ward as a stable patient, the medical doctor on duty ordered for a malaria parasite blood investigation to see if there are more parasites before discharge.Threat To Quality Health Care Essay

Fortunately the hospital management board had enacted a law which governs the hospital and the laboratory in this hospital whereby blood samples are collected by the nurse on duty to the medical laboratory scientist because the hospital had only one medical laboratory scientist that runs the laboratory. The hospital management board tells the Federal Government that they have employed ten medical laboratory scientists (Ghost workers) but apparently employed just one.

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On that faithful morning one of the registered nurses on duty collected this patient blood for investigations but forgot to unfasten the tied tourniquet from the patient’s arm. The incident took place with the morning nurses on duty while handing over to the afternoon nurses the unfasten tourniquet was still on the patient arm so the tourniquet was there for two days without any of the nurses on duty noticing, the patient mum thought the on the girls arm was part of the treatment. 48 hours later a registered nurse on duty who went to give the patient bed bath saw it and by then blood supply to that arm has been cut off.Threat To Quality Health Care Essay

An incident report was filled and submitted to investigated the incidence but information collected could not be worked on appropriately because the structure of the management board is pathologic because they have this attitude already that they needed not to waste their time on patient safety issue (Parker, 2001)

SYSTEM FACTORS
Throughout management of care, registered nurses are used extensively. Most health management officers prefers using advanced practice nurses in their primary care duties in changing patients positions and in community settings. Another important role for the registered nurse is that of case management while on duty. As a case manager you will have to manage care for a patient during the whole of the health care system to minimize breakdowns, contain cost and improve the quality of life.

Nurses also help in a triage role, deciding the most suitable course of intervention and are often employed to render the most appropriate and cost-efficient care. This duty often involves moving a patient out of the hospital, a nursing home or with health service. The patients who are the consumers have different views towards managed care and their experiences. Some patients have good access, care givers they trust, various range of services and fair costs. Others have experienced access problem, refusal of treatment and limited coverage as seen in this case scenario. As patients become more informed, they began to fight for their rights to better health care services through legal system and reforms.Threat To Quality Health Care Essay

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Reducing workforce as seen in this essay, without proper reconstruction simply leaves fewer people to realize already inefficient and ineffective work.Unluckly this short sighted approach is taken by various companies, both in and outside health sector. The outcome is poor morale, patient discontent, low-quality outcome and loss of able staff. Kuokkanen et al., (2003) in their studies noted that job satisfaction, empowerment and organizational obligations are closely linked.

Health care workers today are facing a very different work environment. They mostly have seven to ten different jobs during a typical work career moderately than the three jobs or lesser held by former generation.Threat To Quality Health Care Essay

Keys to successful reconstruction of the health system include strong leadership, support from the leaders from the top (resources, cultural, financial and time) positive thinkers, steadfastness and our being able to answer these few questions:

-What is our mission?

-What standard do we want?

-How do we need to go about our work?

-What people do we want to work with?

The history, political and socioeconomic factors of a country determines the characteristics of the health system, for example the hospital where this incidence occurred ,the organizational models are visionary and do not actually exist in a realistic pure state. Giving the Federal government a false figure of staff in each ward and having few staff is organisational failures that lead to the patient safety incidence. Due to the poor system normal daily nursing procedures were not carried out like taking of vital signs four hourly because if the normal routine procedure of taking vital signs was done the nurse that carried out the procedure would have seen the unfasten tourniquet that was tied on the little girls arm.Threat To Quality Health Care Essay

During handing and taking over of the morning nurses to the afternoon nurses, the blood specimen collection which was a latest development would have been reported to the head nurse on afternoon duty. The nurses on night duty also failed in their duties. If a proper night report was written and read out loudly by a night nurses in the presence of all the day duty nurses the next day the error would have still be noted.

Healthcare managers, strategy-makers and governors at the blunt-end-they decide on how care is delivered through strategies, financial control and directing the work of the healthcare professionals.

At the blunt-end, latent conditions occur. A working environment is made that increases the chances that there will be an active failure at the sharp end. There are a whole lot of latent failures-all with the possibility to cause an adverse event like what we have now in this patient case scenario. The healthcare system in this scenario is overloaded such as overbooking admissions into the ward with less staff. Normally there is a combination of many small factors, each appearing not to be important when viewed alone.

When latent failures occur in addition to only one active failure, such as forgetting to unfasten a used tourniquet by a registered nurse who is overtired because she has been working in an overcrowded and busy ward, the outcome is a recipe for an adverse event to occur.Threat To Quality Health Care Essay

HUMAN FACTORS
Human factor is the application of human knowledge, ability and limitations to the design of common systems of people, work tools and their environment to guarantee their influence, safety and ease of use. The above definition explains it further that the chores nurses perfrom,the equipment they are called to use, their work environment and the organizational procedures that moulds their activities may or may not be a good fit for their advantage and disadvantage. Poor outcome usually occurs when the sensory, behavioural and cognitive traits of providers are put together.Threat To Quality Health Care Essay

Most nursing work processes have evolved as a result of personal or practice first choice rather than through a systematic method of constructing a system that gives rise to small errors and greater effectiveness. Far too often, care givers and administrators have fallen into a current situation trap carrying out procedures simply because they always had been done that way. Experts in human factor on the other hand, look at human abilities and weakness in the construction of systems, stressing the importance of avoiding believe in memory, carefulness and follow up intentions-areas where human acts of avoiding confidence. Processes can be made easy and standardized, leading to less confusion, gains more effectiveness and fewer errors.Threat To Quality Health Care Essay

The area of human factors does not point solely on devices and technology. Human factor research came up during World War II as a result of showcasing equipment and controls that were not fitted to the visual and motor abilities of human users, decade after decade of human factors work has seen a broadening of the human accomplishment issues seen worthy of investigation. Lately a number of human factor experts with interest in improving health care standard and safety spoke addressing a more inclusive range of sociotechnical system factors, including only patient, care givers, the duty performed, and group work, but also work environments or Microsystems. One of the lessons coming from a systems method is that meaningful improvements in safety and quality are likely to be reached by seeing to and correcting the mistakes among these organizational and management matters, and socioeconomic factors outside of the institution. Managing the systems confidence of care, as seen by confidence of care, is a big challenge faced by providers and their human factor partners.

Human factor relevant to this case scenario is that there was an inadequate flow of information from the nurses during their handing over process. The nurses on each shift did not have the information they needed to appropriately care for the young girl. The (Joint Commission) 2006 advices on the improvement of effective communication which is include a requirement for a standardized handing-off of communications. Other human factors that lead to the incident were fatigue, stress and interruptions.Threat To Quality Health Care Essay

Although the nurse that carried out the procedure was not a medical laboratory scientist but she should have explained the procedure to the young girl or get an interpreter to interpret the procedure to the patients mother because she does not understand English. This effective communication before the procedure would have helped in great deal in preventing this accident because the mother caring for her daughter would have noticed the tourniquet still fastened on her daughters arm after the procedure was an error and would have drawn the attention of the nurse or any other nurse to unfasten it.

CONCLUSION AND RECOMMENDATIONS FOR PRACTICE
Increasing the number of medical staffing in order to achieve compliance will help in minimizing patient safety incidence rather than lying. Although increasing the number of medical staff is not a criterion that error will be prevented completely in the practical world.Threat To Quality Health Care Essay

Setting up assessment team amongst the nurses who will be dedicatedly positioned to centralised areas in the ward to assess acutely ill patients and strict monitoring while still on admission.

No matter how bad the case in a hospital is, there must be a patient safety champion in each department or division which should be recommended or nominated by the staff in the hospital.

The hospital should use the information generated by its incident reporting system and organization-wide risk assessments to proactively improve patient care. Threat To Quality Health Care Essay

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