Questions and Answers on Human Factors and Errors in Public Health - Paper Example

The aim of any beneficial health care services is the establishment and delivery of effective, safe, efficient, patient-centered, timely and equitable care within the facilities. Thus, it becomes crucial for all the facility to take into account all the factors that help determine the nature of care delivered to the patients. Of interest are the human factors since every stage of the healthcare delivery process capitalizes majorly on the humans. The World Health Organization (WHO) defines human factors as a science that determines their behavior in different circumstances. In our facility, human factors are defined as those aspects that define how work is delivered, whether in the right or the wrong way and thus determine the patients safety or harm based on the outcomes (figure 1). In healthcare, harm is an unexpected result from the application of a given substance or technique for therapeutic purposes.

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Are 1 in 10 patients in your care harmed?

As the WHO (2009) puts it, 1 in 10 patients within the developed countries, mostly develop deteriorated health conditions due to the introduction of often avoidable human errors. The number of deaths estimated in my line of care, the ICU due to medical errors, tally to up to 98,000 deaths per year in the US as shown in figure 2 which constitute the highest level of medical error at 24% (Dueck and Perri 2005). These statistics indicate that there is a high chance of any 1 person in 10 patients to be harmed by the medical errors within my care thus leading to the harm of the patient.

Detail how adverse events are defined in your workplace

WHO) (2009) reckons that there are many incidences which constitute adverse events in health care. The adverse events constitute those events that cause harm to the patients other than providing health care and involve errors and issues to do with management rather than the disease under treatment (WHO 2009). In our facility, adverse events that lead to a prolonged stay of the patient within the facility or even result in death. Notably, human factors such as fatigue affect the functioning of practitioners which results in adverse events.

What is the rate of adverse events in your clinical area?

Within the Hamad Medical Corporation Qatar, the trend of the adverse events that result to having harmed patients is alike that of the entire Qatar which has not been critically reviewed or researched. There have been difficulties in assessing the patient accident and safety reporting data considering that such practices are deemed as time and resource consuming. However, there has been a documented rate of 7.5% adverse events within the medical sector with approximately 9250 to 23750 people dying in hospitals due to avoidable adverse events and errors (Dueck and Perri 2005). Pagnamenta et al. (2012) record a rate of 2,047 adverse events in the ICU from 6,404 patients on a 17,434 patient day period, which translated to 32 events per 100 ICU patient admissions and 117.4 events per 100 ICU patient days. Further, there have been rates of 9.3 adverse events per 100 patient-day for the ICU case (Roque, Tonini & Prates Melo, 2016).

Take a look at the categories of harm in slide 4 of the human factors presentation. What is the most reported incident in your clinical area?

According to the National Patient Safety (2004), there has been a tremendous increase in the use of technology within the healthcare sector alongside which there has been an increase in the healthcare risks introduced. For instance in my clinical area, the ICU, there are many incidences: fall, procedure related, therapeutic related, diagnostic related, drug related and operation related (as in figure 3). Among all the mentioned harm events, the therapeutic related incidents which include the medical errors and harm events are the most common and outstanding in this clinical area. The error is most common and thus the most reported. However, there are still many scenarios in which the practitioners overlook reporting of typical incidences due to one reason or the other which constitute the reporting barriers.

a) Think about your own practice and in your blog reflect on a common error.

According to WHO in 2009, there are eleven major forms of errors that could occur even in a health institution. These errors are communication, execution, commission, omission, judgment, negligence, violation, procedure, planning, proficiency and decision (WHO 2009). The errors could be well controlled if they were well reported, however, reporting the errors is associated with five main obstacles: information gap, reporter burden, fear, professional identity and other organizational factors. Poorolajal, Rezaie, and Aghighi (2015) and Prevention of Medication Errors in the Pediatric Inpatient Setting (2003) acknowledge that the medical errors are as a result of human mistakes and system flaws.

A common error in my clinical area is the medication device and equipment error. It is evident in figure 4 that the error constitutes the highest rate of occurrence in the ICU clinical area as per the finding of research carried out by Thomas and Taylor (2012). As already hinted out the use of technology has been deemed to increase the efficiency and effectiveness of health care services. However, there have been increased harm events to the patients due to failure or malfunction or even mishandling of the equipment.

Identify how human factors could have contributed to this error.

The medical equipment and device errors are closely related and propagated by the humans. For instance, in my clinical area, many incidences have occurred due to failed machinery operations and inconsistencies in the equipment functionality. The failure of this technology can be regarded to as human factors that lead to the harm of the patients (National Patient Safety 2004). This is so since the failure and inconsistencies of the equipment is due to failed calibration and lack of close monitoring of the equipment. In addition to that, the failure may be as a result of inadequate training of the operator which may range from issues to do with training to issues to do with the management of the facility.

Discuss how human factors could help prevent it.

On the brighter side, there is a clear mitigation of the errors if the human factors are rightfully used. In this case, the human factors can be made relevant if they are changed for the better. For instance, proper and frequent training and educating of the practitioners within the ICU will help avoid those errors caused by inadequate skills of personnel. Also, employing continuous monitoring and maintenance (including calibration) on the equipment is a sure way of mitigating the errors which lead to harm of the patients. There should also be strict policies governing who operates the equipment and how often maintenance should be done with continuous accountability and recording of the same, this will help keep track of any anomaly that occurs before or after any procedure.

Learning from error

Identify the barriers to reporting an error.

Since errors are part and parcel of day to day life they often cause harm within especially within the healthcare sector, it is only wise for anyone to capitalize in knowing what factors, whether human, technological, environmental or any other factors, lead to a given error. Consequently, one can effectively mitigate such an error in future. Also, in case such an error occurs again, the learner will know how well to deal with its consequences in a much stronger way. In a research compiled by the WHO in 2009, there are eleven major forms of errors that could occur even in a health institution. These are communication, execution, commission, omission, judgment, negligence, violation, procedure, planning, proficiency and decision (WHO 2009). The errors could be well controlled if they were well reported, however, the reporting the errors is associated with five main obstacles: information gap, reporter burden, fear, professional identity and other organizational factors. Poorolajal, Rezaie, and Aghighi (2015) and Prevention of Medication Errors in the Pediatric Inpatient Setting (2003) acknowledge that the errors are as a result of human mistakes and system flaws. Therefore, understanding the barriers that are associated with the reporting process, enables one to develop a framework that is workable and effective in developing an error free working place.

In most cases, and as is in real life, people believe that errors are unavoidable and inevitable. Consequently, most people overlook reporting the errors within the workplace since they cannot or have no control over errors. Further, some of the practitioners who engage in near-miss or non-harm errors activities are caught up in a dilemma of whether or not a non-harm error should be reported or not reported. This means that the errors are hardly kept a record of which should be paramount for future error prevention strategies. Poorolajal, Rezaie, and Aghighi (2015) mention that there approximately 62.9% of the staff in the hospital sector find it as of no relevance to report any errors within the institution. Further, approximately 82% of the physicians in the clinical sector have no or have inadequate knowledge of reporting errors if committed. In other words, not all practitioners are willing or even have the proper training on how and when to report errors.

Poorolajal, Rezaie, and Aghighi (2015) further talk of a 60% of the Health Care Professionals who are prone to under-reporting of errors as there are limited and inefficient reporting systems available for within their institutions. This means that poor reporting systems are a major barrier to the process under review and that much should be invested in developing resourceful and effective modes of error reporting. For instance, there are cases in which the reporting materials (such as the paperwork) are too much such that the staff under review lacks enough time for recording each error done under his/her watch. There have, however, been introductions of radio communication and other electronic or digital reporting systems so as to mitigate such reporting barriers that are related to much work load and time consumption. There have also been online avenues of reporting which have eased the process of reporting and have been seen to encourage reporting in most health care facilities.

Another barrier of reporting errors can be related to the aspect of fear. In this case, there are two extremes, those who dismal errors and those who see big errors as big issues. In this case, those who see the error as a big issue end up not reporting big or serious errors whereas those who have made small errors tend to overlook reporting the same. These two extremes become major barriers to reporting errors. It is good to mention that the fear of reporting errors mainly revolves around the need to uphold ones reputation; the fear of losing ones job or position within the institution; the fear of ones license being suspended; the fear of been sanctioned, chastised, ostracized or punished; the fear of being victimized, reattributed or receiving appraisals; and the fear of being held personally responsible for the occurred error. There is also an aspect of those making the errors fearing that their rights would be violated if they...