Why Mistakes Happen
Health care institutions and organizations must comply with federal and state regulations and industry standards, subject to inspections by organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO acts as an impartial organization to ensure health care providing institutions meet industry standards.
Health care institutions are required to ensure each member of the team meets the necessary standards to perform their job. This includes education, experience, and credentials, in addition to verifying any potentially disqualifying information, such as a felony criminal record. What is required by institutions to reach beyond this minimum standard and create an environment that sets health care workers up for success and allows patients to have better outcomes?
The intensive or critical care environment, including the neonatal intensive care environment, is prone to intense complexity.
Human errors are inevitable. People are subject to cognitive processing disruptions and mental fatigue. The inpatient hospital environment is complex. The intensive or critical care environment, including the neonatal intensive care environment, is prone to intense complexity. Add to this complexity an emotional burden of fear of failure, both as a human and as a nurse in the critical care culture.
James Reason developed a model to explain human factor analysis and the occurrence of errors. Potential factors included in this model are the leadership that allows for staffing shortages, technical support lacking needed algorithms and procedures, incorrect or incomplete training of staff, and poor teamwork. Both a practical and institutional level of error reflection and corrective action is required.
There are simply more opportunities to create an error in a critical care setting.
One in ten patients encounters an error in health care provision, and the complexity of situations in critical care enhances this risk. There are simply more opportunities to create an error in a critical care setting. Errors include hospital-acquired infections and injuries, as well as medication errors. Medication error rates, for example, are as high as 80% in the intensive care environment, according to one study.
There are many dimensions to creating a culture of safety. The most highly ranked among nurses include teamwork within units and continuous improvement with organizational learning. When nurses are asked about the non-punitive error reporting system, however, nurses did not feel that this was implemented at an acceptable level to promote a safety culture.
Most health care systems have realized that error reporting without repercussion is an essential part of the culture of safety. This allows errors to be discussed in a way that allows everyone to learn from the errors and institute a new process needed to ensure safety. However, nurses continue to be fearful of being blamed and suffering the consequences of reporting an error.
Nurses need the ability to identify areas where improvement is needed and the freedom to discuss and act upon them.
Nurses are the central hub to the health care team and serve in an influential role. Essential to this role is the ability of the nurse to identify areas where improvement is needed and the freedom to discuss and act upon these areas.