Analyzing Errors and Root Causes

Errors and Root Causes

Why do Errors Happen? How Can We Prevent Them? (Dr. Lucian Leape's video)

Error is defined as the failure of a planned series of physical or mental activities to attain its planned outcomes, when these failures cannot be attributed to possibility. Errors do not just happen in institutional or inpatient surroundings, but in all surroundings. Errors frequently occur as a result of convergence of several contributing factors. In almost all industries, one of the main contributors to accidents is simply human error. Majority of the errors happen because of equipment failure. Errors could be avoided by: redesigning of the respective equipments to default, a safe mode; minimizing the variety of device models bought; applying clear procedures for checking the respective supplies, equipment and many more; orientation and training of new personnel with the team(s) with which they shall work with, offering a supportive surrounding for recognition and communication of errors for organizational learning and change (O'Daniel & Rosenstein 2008).

What are the main obstacles preventing health care agencies and professionals from learning from one another's mistakes? The healthcare system's delivery procedures entail several interfaces and patient handoffs amidst numerous healthcare practitioners with different levels of professional and academic training. When healthcare experts are not effectively communicating, patient safety is in danger for various reasons: lack of important data, misunderstanding of data, and ignored changes in status. Absence of communication develops circumstances whereby medical errors are most likely to take place. These errors have the capability of resulting to severe injury or even sudden death of the patient. Medical errors, particularly those as a result of communication failure, are a pervasive issue in the current healthcare system. The collaboration and communication obstacles that exist amidst clinical personnel frequently jeopardize the attempts to enhance healthcare quality and safety. Other barriers hindering healthcare practitioners and agencies from learning from each other's mistakes include: disruptive conduct, ethnicity, and culture; generational variations; gender; past intra-professional and inter-professional contentions; variations in language; different levels of preparation; and variations in responsibility, payment, and rewards (O'Daniel & Rosenstein 2008).

How would you classify the barriers? Are they cultural, territorial, legal, technological, political, or financial? These barriers are basically cultural barriers because cultural diversity makes communication a challenge, as the way individuals of differing cultures think and behave, vary. Different cultures have different meanings of gestures and words. Also, culture results to manners, views, ethnocentrism, and prejudices that differ from one to another.

How would a nursing leader design an ideal system to keep identical, fatal errors from happening in different places? Chief Nursing Officers (CNO), together with senior leaders, are the key actors in the journey of healthcare transformation, when it comes to avoiding similar, serious errors from occurring. Nursing leaders are faced with the responsibility of aiding in the closure of gaps in board member's comprehension regarding quality, in addition to being the advocates of patient safety and quality care. Doing so requires CNOs to exercise leadership skills and implement strategies for manipulating other individuals in the organizational structure above and below the nurse leader. Use of self as a knowledgeable professional and a role model influences the ability of CNOs to change the values, beliefs, and conduct of the board members and also to reduce gaps in their understanding of and involvement in quality initiatives (Mastal&Schulke 2007).