Patient safety is an important core value of nursing practice so efforts to overcome barriers to preventing patient harm (like those discussed in a prior post) are worth our energy and attention. Sometimes getting quick results can reduce resistance to the changes needed to decrease clinical error. I’d like to suggest four ways to quickly move forward on improving patient safety in any setting.
Communication breakdown has been the most frequently cited cause of clinical error so this is an excellent place to start. If you are a leader, evaluate the various hand-off points in your primary care systems and work to tighten them up. Also take a good look at communication among disciplines, including your staff and officers. For example, are there conflicts and poor relationships that are getting in the way of smooth operations.
Human Factors Engineering
Human factors engineering (HFE) may be an unfamiliar term. It refers to developing systems that take into account human error by implementing safeguards or barriers to common human error points. HFE has reduced errors in other high-risk industries like nuclear power and space travel. Here are a few examples for health care:
- Reducing reliance on memory with whiteboards or checklists for important care processes
- Improving information access at the point of care such as easy availability of treatment protocols and drug information where care is delivered
- Standardizing tasks so that all members of the team perform the task in the same way.
Involving patients in their care is not always a popular concept in the criminal justice system. However, if you are returning to your health care roots and centering on the patient, it makes sense to involve them in their care. Patients are able to assist in reaching an accurate diagnosis. Certainly the more you are able to have an open and honest dialogue with your patient the more likely you will get accurate information to make a diagnosis. Patients can also provide feedback on effects and side effects of treatment. If your patient is engaged as an active member in the care team, he can speak up when something is amiss such as identifying when a treatment or medication is missing or different than expected.
You can also engage some members of your patient population in program improvement activities. For example, trusted patients or inmate councils can provide input into system changes that affect them. The inmate grievance process can also be used to improve patient safety if used to evaluate trends in complaints.
The final recommendation is simple, yet difficult at the same time. Be continually mindful of patient safety when going about care tasks. Mindfulness is the increasing ability to experience being present with acceptance, attention and awareness. Attention and awareness to the potential for patient harm in everyday clinical situations can go a long way toward averting errors in practice. Just reading about patient safety is likely to increase your awareness but that can fade quickly if patient safety does not become part of the fabric of how health care is delivered in your setting.
Have you overcome barriers to implementing patient safety processes? Share your experiences in the comments section of this post.