The Wall of Silence is simply a brilliant book that has the potential to scare those needing healthcare services. This book can also and should also open the eyes of healthcare professionals to the idea that errors will happen, and instead of being ignored they should be analyzed to stop them from happening again. The purpose of this journal is to reflect on medical errors and on how can the nurse help to reach zero mistakes.
Awareness Level
Healthcare professionals have been respected throughout history because they are thought to always have the right answer due to the years of education and research that they have received. On the other hand, people rather be optimistic and never think the doctor can be wrong than to admit the fact that medical errors are responsible for so many deaths. Before reading The Wall of Silence, my awareness of errors in the healthcare sector went as far as “… well, accidents can happen”, but never imagined 275 deaths a day because of these “accidents” (Gibson and Singh, 2003). The saddest part was to learn that such mistakes were taken lightly and no corrective action was on place.
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World War II Veteran
Ockie, a 75 years old World War II was diagnosed with esophageal cancer according to Gibson and Singh. He was ready to go through chemotherapy and radiation to shrink the tumour before the surgery needed to remove the tumour. His daughter and wife were by his side through the entire process. In October of 1998, Ockie came out of a successful 6 hours and a half surgery and was placed on an intensive care unit for his recovery before going home. On the fourth morning after the surgery, his daughter and wife came to visit him as every day and found out that the nasogastric tube had come out the night before. The nurse reinserted the NG tube but into the lungs instead of his stomach. Such a small mistake became pneumonia, and then he was connected to life support until his kidneys failed because the many drugs are given to fight pneumonia. In March of 1999, Ockie died from a hospital-acquired infection, not from cancer initially diagnosed.
Nasogastric Tube Guideline
The review of Ockie’s case should have brought up a process where preventing measures could be taken to avoid similar scenarios. The first mistake was made when the nurse ignored the already written order from the physician of not repositioning the NG tube in case that this one came out. Today, the Elsevier (2017) clinical skills guideline teaches nursing students in bold red letters to not reposition NG tubes in patients that have undergone upper gastric surgery to protect the suture line. Ockie's nurse did not rupture the suture line from the esophagus surgery, but because the inflammation and vulnerability of the area, the repositioning should have been made by the physician and confirmed by radiography. Capnography is another method used today, more efficient than pH measurement and audible air bolus, which confirms placement by detecting CO2 (the lungs) or not (the stomach). There is more safety emphasis now on placing NG tube because an evidence-based practice has shown what can happen in patients like Ockie.
Ockie’s Case
The stories in this book speak by themselves about the pain and suffering of many families around the United States, but most importantly they bring awareness of an imperfect system that needs to continous review. While reading through their past experiences with the health care system, I felt angry to the CEOs, managers, and to the system itself for not trying to learn from their mistakes. "To Err is Human" but to swipe it under the rug, give no apologies, and no help, like if the healthcare system was God itself is beyond wrong. The error in Ockie's case was by the commission because the nurse performed an action (reinserting the NG tube) that led to harm the patient (Gibson and Singh, 2003). The story about Ockie attracted me because he was a veteran like me, a survivor by nature, a survivor of World War II, and a cancer survivor for all we know. And when he less expected it, when his guard was down, a simple mistake took his life, and the hospital did not even acknowledged it or also apologized to his family. It takes a cold heart and a broken system to take Ockie's death as another number that will not teach a lesson about avoidable mistakes.
Non-disclosure of mistakes is a culture that characterized the nursing practice contrary to the code of ethics. Nurses fail to report medical errors to patients because of the culture club where reporting translates to disloyalty. An attempt for a nurse to report leads to them threats of with reprisal. One consequence of failure to report is increased medical mistakes has no consequences are faced. Failure to report also results in improved patient mortality rate and worsening of conditions (Gibson & Singh, 2003). Medical standards are compromised, and patients pay the price of inadequate health care quality.
Shortage for Nurses’ Effect on Safety and Potential for Error
Lack of sufficient skilled and qualified nurses is a major problem in medical care that affects the safety of care and creates room for mistakes. With the shortage of nurses, they work for more extended shifts and attend more patients leading to a high nurse to patient ratio. Out of exhaustion and pressure of handling so many files errors and negligence are most likely to occur (Gibson & Singh, 2003). Shortage of nurses increases the potential for medical errors as nurses under pressure may miss a sign or delay in giving attention to patients. Patients suffer inadequate care due to lack of an attending nurse.
Frequency and Significance of Medical Errors
Medical errors pertain to mistakes in practice and errors in the system. The facts on the rate of medical mistakes are unknown due to the underreporting of such cases. Usually, data on search cases are collected from patients and families who have been victims of medical errors. Studies show that the frequency of medical errors is higher than recorded data accounting for about 100, 000 deaths annually. Only about 30% of mistakes are recorded and usually minor mistakes. Significant mistakes, especially from surgery departments, go unreported hence the lack of clarity of the actual frequency. Medical errors are very substantial in health care due to their adverse effects on the patients and healthcare standards (Gibsoin & Singh, 2003). However, from experiences the frequency of medical mistakes is high and high subsidizes the quality of health care.
Experiences in Managing, Correcting and Documenting Medication Errors and Effect on Practice
The management, correction and documentation of medical errors are poor in practice. With so much retribution attached to reporting of mistakes, errors often go undocumented, uncorrected and therefore are unmanageable. Ultimately, attempts to report and correct medical errors face politics and may amount to the loss of jobs. The culture of cover-up, though unethical, is greatly experienced in medical practice concerning medical mistakes. Patients often end up suffering from the errors and may never know the role physicians played in their deteriorating health conditions. Therefore, overall the management of medical errors is weak and almost non-existence leading to unsafe and substandard practice.
Need for Quality Improvement
Quality and patient safety are the primary objectives of healthcare provision. Any practices that compromise quality or security need to be eliminated from the system. Health care deal with people’s health and lives and as such the need for high-quality care and caution in provision. Given that medical errors cost the nation over $19 billion due to additional medical costs of prescription drugs, the supplementary services leads to more extended periods of health care. In complex cases, poor quality results in deaths which cause loss of livelihoods in the case of breadwinners leading to more psychological effects on the family left behind (Andel, Davidow, Hollander & Moreno, 2012). Hence, there is a need for quality improvement in the delivery of healthcare services including improvements in reporting, correction and management of medical mistakes.
Valid and Reliable Information
Consumers of health care find information about health care providers and facilities in many ways. Consumers may seek reviews from their friends and other clients of the hospital on the type of care in the facility and the state of the facility. Usually, facilities and providers services are reviewed by experts and researchers and the information mainly aids in consumers deriving valid information about a facility. The internet dramatically assists in getting a variety of reviews from frequent clients at the facility and deciding the reliable information depending on the positivity of the reviews (Gibson & Singh, 2003). The National practitioner data Bank is also secure for information about doctors and health practitioners and their ratings in the delivery of care.
Consumer Investigation of Providers
Consumer investigation on care providers before accessing care in a facility is essential to reduce the chance of falling victim of sub-standards and inadequate care. Consumers are becoming more and more investigative on health care providers with the increasing revelation of medical errors. States are providing databases with information about health care facilities and practitioners which illustrates increasing consumer investigation of providers. As a consumer, it is important to get reviews from other consumers about the services in a facility and the state of the facility. Information from national records also comes in handy in reviewing quality and safety of providers' services.
Quality Improvement Effect on Regulatory and Accreditation Reporting and Reimbursement
Quality improvements systems enhance regulations and accreditation reporting and reimbursement. With quality improvement systems, practitioners are dedicated and work diligently to deliver safe and quality care. Quality systems ensure there is no bias against medical staff who report mistakes and hence improves the level of correction and management of errors. Quality improvements increase nurses’ rate of staying in provider facilities as they feel free to deliver safe and quality care without intimidation. Quality improvements also ensure that the right institutions with high accord for quality and safe delivery of health care are accredited.
Issues on the Use of Information and Technology in Healthcare Provision
Using information and technology would go a long way in managing knowledge, mitigating errors, enabling communication and supporting decision making in healthcare provision. The issues surrounding information and technology are efficiency and the role they play in allowing quality care. Sharing of information is critical to mitigating errors in health care and passing on knowledge to support medical decisions. Technology comes in handy in enabling fast and reliable transmission of information necessary for adequate health care. Technology influences practice by allowing advanced approaches to care which are more effective. Technology offers speedier transfer of knowledge and higher level of coordination. Technology also improves the methods of care through machines and systems that ensure quality and safe care. In the future, technology is expected to reduce the costs of healthcare while significantly improving quality. Technology will continue to play a critical role in the management, coordination and support of the large medical data on patients in ensuring effective treatment approaches (Thimberly, 2013). The vas use of technology will increase patient power and consumer education of health care, conditions and the safety of healthcare procedures.
Health Care Industry vs. the Aviation Industry
In comparison to the aviation industry, the health care industry is lenient and compromising on quality and safety. Aviation industry professions have in place channels to report situations that compromise safety in confidence eliminating the threat of intimidation. The national transportation safety board is responsible for investigating and disciplining incompetent aviation personnel who place the risk on security. In the healthcare industry, physicians resume work as usual after the disciplinary action which is the hospital's obligation creating room for bias and under investigation. The healthcare industry is yet to put in place confidential reporting channels that eliminate the threat of intimidation to practitioners who make medical error among other risks to quality and safety (Gibson & Singh, 2003). Therefore, the healthcare industry is weak in quality and safety measures and practices compared to the aviation industry.
In conclusion, medical mistakes are a common risk to quality and safety in healthcare facilities. The mistakes are underreported hence the unreliability of health care system and the need for consumer scrutiny while seeking medical care. Patients make the most reports of medical errors since practitioners promote the non-disclosure culture which is unethical. Patients are the most affected by the consequences of medical mistakes and underreporting hence prompting care seekers to be more proactive in seeking health care providers. The promotion of quality and safety objectives in the healthcare industry is weak compared to other high-risk sectors like aviation. Therefore, there need for improvement in health care systems is paramount.
References
Andel, C., Davidow, S. L., Hollander, M., & Moreno, D. A. (2012). The economics of health care quality and medical errors. Journal of health care finance , 39 (1), 39.
Elsevier, Clinical Key for Nursing. (2017). Nasogastric tube: Insertion, irrigation, and removal. Retrieved from: https://www-clinicalkey-com.ezproxylocal.library.nova.edu/nursing/#!/content/nursing_skills/63-s2.0-GN_34_5
Gibson, R., & Singh, J. P. (2003). Wall of silence. Washington, DC: Lifeline Press.
Thimbleby, H. (2013). Technology and the Future of Healthcare. Journal of Public Health Research, 2 (3), e28. http://doi.org/10.4081/jphr.2013.e28
