Name
Chamberlain University
NR-544: Quality & Safety in Healthcare
Prof. Name
Date
The review of the simulated case reveals that both human and system factors played a role in the adverse outcome. As Alam (2020) explains, “the interaction of humans with healthcare systems poses risks mainly because of complex technology, demanding procedures, high service demand, time constraints, high patient expectations, and hierarchical structures in training and responsibilities.” Upon initial examination, it appears that human error was a significant contributor to this outcome. However, system-related shortcomings at the nursing home also aligned with the human component to cause the failure.
To better understand the causes of this incident, it is important to address several questions:
The contributing factors may be better assessed through the following guiding questions and responses:
| Question | Answer |
|---|---|
| Is the facility truly utilizing paper charting and medication reconciliation? | If the nursing home still relies on paper charting, the chances of transcription mistakes and incomplete documentation increase significantly. Paper systems lack automated alerts that electronic systems provide, making errors harder to detect. |
| What are the staffing levels, and how do they contribute to workload and fatigue? | Inadequate staffing levels often lead to nurses handling higher workloads, resulting in fatigue and decreased attention to detail. Overworked staff are more prone to medication reconciliation errors. |
| Are there mechanisms in place to allow for uninterrupted medication reconciliation? | Interruptions during medication reconciliation are a common cause of errors. If the facility does not ensure protected, interruption-free time, mistakes are more likely to occur. |
| Are there protocols or standing orders for acute medical episodes? | Without clearly established standing orders or emergency protocols, staff may hesitate or delay in managing acute conditions, which can worsen outcomes. |
To prevent future breakdowns in care, it is critical to identify whether the error stemmed from human error, system error, or a combination of both.
Human Error: May include carelessness, distraction, or failure to follow protocols.
System Error: May involve outdated charting methods, poor staffing ratios, or lack of standardized procedures.
Another aspect to consider is the cost of remediation. Retraining staff and implementing policy changes are more cost-effective, but over time these measures may drift if not reinforced. On the other hand, adopting electronic charting systems is a long-term but expensive solution that could reduce documentation errors and improve patient safety.
Before applying a specific model to investigate the event, it is essential to determine:
Was this an isolated incident?
Were there any “near misses” that could indicate a broader systemic issue?
Our lesson this week suggests several theories for investigating healthcare errors. One valuable approach is Heinrich’s Domino Theory, which emphasizes that accidents are primarily the result of unsafe acts rather than unsafe conditions (Albrecht et al., 2000). Although introduced in 1931, this theory still holds relevance today.
For this case, the human component is central. Questions such as Was the error due to distraction or carelessness? must be carefully analyzed to understand the underlying causes.
To reduce the risk of similar incidents, the following changes are recommended:
Double-Check System: Implement a mandatory double-check process during medication reconciliation.
Protected Reconciliation Time: Ensure staff can perform medication reconciliation without interruptions.
Standardized Protocols: Develop standing orders for acute medical episodes to guide immediate action.
Technology Integration: Transition from paper-based systems to electronic health records for better accuracy and monitoring.
By adopting these strategies, healthcare facilities can strengthen both human and system components, leading to safer patient care outcomes.
Alam, A. Y. (2020, October 3). Steps in the process of risk management in healthcare. Journal of Epidemiology & Preventive Medicine. Retrieved September 21, 2020, from https://www.elynsgroup.com/journal/article/steps-in-the-process-of-risk-management-inhealthcare
Albrecht, J. S., Gruber-Baldini, A. L., Hirshon, J. M., Brown, C. H., Goldberg, R., Rosenberg, J. H., & Furuno, J. P. (2014). Hospital discharge instructions: Comprehension and compliance among older adults. Journal of General Internal Medicine, 29(11), 1491–1498. https://doi.org/10.1007/s11606-014-2956-0
