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Medical Errors and Systems Thinking

Medical Errors and Systems Thinking

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IV insertion in armMedical malpractice attorneys often discover that medical errors occur and patients are injured due to flaws in the healthcare system. Yet the focus of the legal system is on identifying individuals who contributed to an error that harmed a patient. For example, in order to get beyond the $250,000 charitable immunity cap in New Jersey, a plaintiff attorney must name a hospital employee, such as a nurse, as a defendant in addition to naming the facility.

Shame and Blame Approach to Medical Errors

In the past, and still to an extent today, people who made errors were punished – disciplined, suspended or fired. There are some individuals whose errors are so egregious that they should be disciplined, but others have made errors because of flaws or holes in the system.

The risk management/risk prevention sector has long recognized that the shame and blame culture inhibits people from reporting errors.

Several studies have verified that there is a dramatic increase in reported errors when facilities actively encourage anonymous reporting. For example, a pediatric ambulatory care practice proactively encouraged reporting of errors. This was voluntary, anonymous, and non-punitive reporting. The prior year, there were 5 errors reported.

After encouraging all staff to report adverse events and near misses, there were 80 error reports completed that year. The staff acted on the reports and rapidly made changes to improve patient safety.

Systems Thinking About Medical Errors

Risk management thinking shifted from shame and blame to a “just” culture which focuses on not punishing people for reporting medical errors, but instead addressing and correcting the system issues that contributed to the error. System has its roots in Latin and means “to cause to stand together”.

Medical errors are often caused by a domino effect. One error follows another, and the flaws in the system permit the error to reach the patient. (Too young to know dominos? These are wooden blocks that are lined up close to each other and knocked down. I know, it seems rather unexciting in the digital age.)

Healthcare providers are learning how to use “systems thinking”: to understand and value how the components of a complex healthcare system influence the care of a patient. The competencies doctors and nurses need to function in a highly complex environment are now more clearly defined.

Physician Competencies to Prevent Medical Errors

Physician competencies are defined by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties. These competencies are required of residents and physicians to deliver high quality medical care.

They include:

  • Patient care
  • Medical knowledge
  • Practice based learning and improvement.
  • Interpersonal and communication skills
  • Professionalism
  • Systems based practice.

Practice based learning and improvement asks, “How can I improve care for my patients?” System based practice asks, “How can I improve the system of care?”

Nursing Competencies to Prevent Medical Errors

Nursing competencies come from The Robert Wood Johnson Foundation funded project called Quality and Safety Education for Nurses. They made a major contribution to healthcare education by creating these competencies, which were modeled after the Institute of Medicine reports called To Err is Human and the follow up report, Crossing the Quality Chasm. Each of these 6 competencies is accompanied by statements which guide nursing education both before and after licensure. National nursing organizations, the National Council of state Boards of Nursing and textbooks have incorporated these competencies.

Nursing competencies include:

  • Patient centered care
  • Evidence based practice.
  • Quality improvement
  • Teamwork
  • Collaboration
  • Informatics

The key to avoid repetition of medical errors to view how the system contributes to the error and to make changes. Sometimes a medical or nursing malpractice case brings the flaws to light and the healthcare staff make the changes needed to create a safer healthcare environment. At other times, because the error is hidden, or not acted on, or the system not fixed, the facility staff are doomed to repeat the error.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.

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