A medical error is defined by the Institute of Medicine

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A medical error is defined by the Institute of Medicine as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (L, 2006). Thousands of the deaths are occurring because of human induced mistakes which must be taken into account in order to provide safe, effective, standardized, qualitative medical care to all patients in hospital as well as in follow up care. QUESTION NO. 1. What human factors issues did you identify? There are some human factors and issues that I have identified throughout my past experiences. There are certain factors responsible are given below:1. Knowledge and skills: knowledge and skills in practical field are required in each and every professional because there is no chance to improve or correct for most of the mishappenings that has occurred where it goes to irreversible stages. Health professional must be fully knowledgeable and trained in their respective field. An untrained professional must be supervised during his task performance.

2. Illness, fatigue, Stress, Anxiety and emotional disturbances: Health personnel with mental instability can never concentrate on his or her work. I have my own experience, one nurse in general ward was in emotional stress because the death of her father. She was caring for a diabetic patient and forgot to give him oral hypoglycemic drug. It resulted into high sugar level for that client.3. Inadequate staffing: In some situation like in mass causalities, nurse per patient ratio get affected due to insufficient staff and shortage of time. One nurse has to do personal care, procedures, sampling and so on things on all assigned patients .So, it also affect quality. 4. Poor or disrupt communication: It has been reported that poor communication among healthcare personnel or between patient and healthcare personnel can lead to medication errors. There is a need for designing strategies for effective communication and teamwork amongst healthcare professionals, which can consequently influence the quality of healthcare services and therapeutic outcomes. (Shitu, 2018)5. Unfamiliarity with devices: It is observed that inability to understand and operate new devices in patient care settings leads to wrong electronic errors which further mislead the treatment plan and interventions.

QUESTION NO.2 : Where there processes in place to reduce the risk of error? If so, what were they?As per my experience I have seen and practice steps to avoid errors as much as possible while performing care for patients. These steps can reduce the risk to error.1) Double or triple check of medication: I used to check the medication three times usually at my workplace. At the taking from shelf, then before extracting it from label and at giving. I followed 7 RIGHT’S of medication administration:  Right patient Right drug Right assessment Right dose Right time Right route Right documentation2) Check label of blood bag: Mismatched blood infusion can lead to sock and death of client. I have worked in blood bank as a student and learned about cross matching, identification of different blood groups. I practiced all precautions before starting blood infusion to patient. 3) Clear labeling of emergency drugs in unit inventory: Some medications are looked alike so these must be properly labeled in bold letters and keep safely. Staff was managing the inventory correctly to make sure the correct use of medicine and avoid its misuse. 4) Clear documentation: I did paper documentation at my workplace every day and given over to next shift nurse with care especially to medicine entry, infusions intake, SOS medicines, NPO status of client, precautions etc.

QUESTION NO. 3: Are there systems in place to minimize the risk of error?There are several systems in place to minimize the chances of errors.1. Electronic health records: Computerized reporting of lab records, computer-based procedure reminder systems, software that supports diagnosis and treatment decisions with clinical guidelines. According to a study, EHRs can improve patient safety. Thus, it is necessary to design systems with specifications that support patient safety. (Ahmad, 2019)2. Computers and Barcode Systems Ensure Proper Procedures: These systems are used to verify the dose, timing, patient, particular medication, delivery route. Many health systems use digital platforms and barcode scanning systems when checking each of those areas for correctness. For example, a nurse might scan a person’s hospital wristband to check identification, as well as target a barcode on the medication container, then check the scanned information against what appears in a computer interface. (Preventing Medication Errors With Technology)3. Sponge detection: Many hospitals are investing in bar-coded or RFID-chipped surgical sponges. Instead of keeping tally in their heads, surgical staff simply scans a sponge’s barcode or pass the RFID-chipped sponge in front of a sensor and the computer keeps count and knows exactly which sponges need to be accounted for.4. Computerized Physician Order Entry: Technology is used to reduce prescription errors in other ways. Computerized Physician Order Entry is a system that allows doctors to electronically order medications, tests and procedures directly using the hospital’s main system. 5. Iris Scanning: The system scans eye using video camera technology and near infrared illumination to capture the intricate details of the unique patterns found in the iris. In a healthcare setting, this technology can be used to ensure that patients are who they claim to be and may help identify incoherent or unconscious patients in emergency departments. (Ankin, 2015)

QUESTION NO. 4: Explore and describe other strategies which might be considered to minimize the opportunities of error?These steps we can follow to get safer care:- Reduce medication error: Proficiency in drug calculations is essential for safe medication administration. Having sound basic mathematical skills and performing accurate drug calculations can significantly minimize medication errors. (Simple steps to reduce medication errors, 2016) Always follow 7 RIGHTS for medication administration  Reduce risks during surgery: Surgery at the wrong site for example, operating on the left knee instead of the right happened but rarely. This error can be eliminated by prior identification in pre-operation room then before entering OT, tie patient identification on wrist of patient who is undergoing surgery. Counting sponges and used instruments used in surgery before stitching the incision to prevent sponge or instrument inside the body. For instance, during exploratory surgery it is common. Place the identical medication with care to avoid wrong administration. Proper labeling of medicines can help to minimize confusions between similar looked medicines. Prompt documentation: means to document the given medicine soon after administration to avoid doubling.  Choose the right staff for the job: It is important to identify people the capabilities necessary to perform the job safely. Staff members should be trained well for their job and have skill and knowledge to recognize a potentially medical error.(Pinder, 2018)