Monday, June 08, 2009

Prevention of Medical Errors - Leveraging the power of science and compliance to prevent catastrophe

Article on Advance web for LPNs website by Barbara L. Olson

A lot of useful information in this article about human factors in general, and particularly medical error. I have to say that for a publication that claims to be for practical nurses, this article is so full of unnecessary human factors and psychological jargon that the key messages may well be lost, which is a real shame. Why can't people write clearly?

One of the messages seems to be that healthcare does not act in the same way as 'high reliability organisations.' In particular health care professionals are "more likely to accept broadly stated goals as the functional unit performance, rather than process-orientated steps that contribute to a larger outcome." I think this means that there is more responsibility put on individuals to act safely and less emphasis on improving systems to reduce the risk of error.

The article suggests a risk-reduction hierarchy that I think is good:
* Forcing functions and constraints
* Automation and computerisation
* Standardisation and protocols
* Checklists and double-check systems
* Rules and policies
* Education and information
* Suggestions to be more careful.

Andy Brazier

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