The majority of the hospitals in the US do not learn from past incidences of medical errors. One of the reasons for this trend is the lack of appropriate systems that could inform the health practitioners about recent adverse events and introduce solutions to avoid the reoccurrence of an error. In most cases, the healthcare system blames the individual nurses and physicians instead of focusing on improving a system that allows and encourages the possibility of medical errors. Another reason for this trend is the inadequate communication tied to sentinel events—unexpected occurrences that can result in death or physical and psychological injuries (Manias, 2018). Notably, the healthcare system has not created policies that foster communication among health practitioners. Another reason for the repeated occurrences of medical errors is the failure to document the history and causes of errors accurately. As a result, health practitioners are unable to identify error-prone events.
More importantly, the barriers that prevent learning are cultural. The majority of the healthcare facilities have put in place rigid policies that focus on punishing health professionals ( Rodziewicz & Hipskind, 2020 ). As a result, the members of the staff are unlikely to report, document, or minimize the magnitude of an error. As a result, healthcare institutions continue to record a repeat of medical errors. Besides, the term “error” has been demonized to the extent that no healthcare institution or healthcare expert wants to be associated with it ( Rodziewicz & Hipskind, 2020 ). The culture of blame has damaged the confidence, esteem, and morale of the accused health professionals. Instead of learning from their past mistakes, they offer inadequate medical services since they focus on error prevention.
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Nevertheless, I can design a system that will prevent fatal errors from occurring in different places. Under this system, there will be a useful interdisciplinary collaboration between health professionals that will foster the sharing of objectives, collective decision-making, and shared responsibilities (Manias, 2018). Such an approach will enable health professionals working in different disciplines to share their experiences and make informed decisions that will prevent the occurrence of errors in the future. In this system, there will be accurate assessment and documentation of errors at the end of every day. Then, the errors will be reviewed every week to identify error-prone areas and offer the best risk mitigation strategies.
References
Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: An integrative review. Expert Opinion on Drug Safety , 17 (3), 259-275.doi: 1 0.1080/14740338.2018.1424830
Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. In StatPearls [Internet] . StatPearls Publishing.
