MGMT 415 Module 2 Assignment: To Err is Human

Introduction to MGTM 415 Module Two Assignment

In the MGMT 415 Module 2 Assignment: To Err is Human, you are tasked with analyzing a healthcare error, identifying its potential causes, and proposing quality improvement strategies to detect the error and prevent patient harm. This How-To MGMT 415 Guide will provide clear, concise instructions for each assignment section, ensuring a thorough and professional analysis.

Describe the error.

Describing the Error

To start the MGMT 415 Module 2 Assignment: To Err is Human, we will discuss the error in the Institute of Medicine’s “To Err is Human” report (1999).

• Choose a healthcare error that is well-documented and significantly impacts patient safety.
• Examples include medication errors, surgical errors, diagnostic errors, etc.
• Explain the nature of the error.
• Describe the context of the error (e.g., hospital setting, type of care, involved personnel).
• Outline the consequences of the error for the patient(s) involved.
• Include any immediate and long-term effects on health and well-being.

Example

One prominent healthcare error documented extensively in the Institute of Medicine’s (IOM) “To Err is Human” report is medication errors. These errors occur when there is a mistake in prescribing, dispensing, or administering medication, leading to harm or potential harm to patients. Medication errors are prevalent and can have significant implications for patient safety.

The nature of medication errors can vary, including incorrect dosages, wrong medication given, or medication administered at the wrong time. These errors often arise in complex hospital settings where multiple healthcare professionals interact with patients. For example, a nurse might misread a prescription, or a pharmacist might dispense the wrong drug due to similar drug names.

The consequences for patients can be severe, ranging from minor discomfort to life-threatening conditions. Immediate effects might include adverse drug reactions, while long-term effects could involve prolonged hospital stays, permanent injury, or even death. For instance, a patient receiving an incorrect dosage of insulin might suffer from hypoglycemia, leading to seizures, unconsciousness, or long-term neurological damage.

Identify possible causes for the error, explaining the connections between it and its potential causes.

Identifying Possible Causes for the Error

Next, we will discuss the possible causes of the error.

• Examine human error, system failures, communication breakdowns, and environmental influences.
• Use relevant frameworks or models (e.g., the Swiss Cheese Model) to structure your analysis.
• Link each identified cause to the error.
• Use evidence from literature and case studies to support your explanations.
• Conduct a root cause analysis to identify underlying issues.
• Focus on systemic problems rather than individual blame.

Example

Identifying the causes of medication errors involves examining multiple factors, including human error, system failures, communication breakdowns, and environmental influences. Human error is often a significant factor, stemming from fatigue, inadequate training, or cognitive overload. For instance, a nurse working long hours might misinterpret a prescription due to exhaustion.

System failures are also critical contributors. Poorly designed healthcare systems, such as confusing medication labels or complex electronic health records, can lead to mistakes. Communication breakdowns, such as unclear doctor instructions or incomplete handovers between shifts, further exacerbate the issue. Environmental factors like inadequate lighting or high noise levels in hospitals can distract healthcare workers, increasing the likelihood of errors.

The Swiss Cheese Model is useful for understanding how these factors interconnect. This model suggests that errors occur when multiple layers of defense (like cheese slices) have holes (weaknesses) that align, allowing an error to pass through. For example, a poorly designed electronic health record system (system failure) combined with a tired nurse (human error) and a noisy environment (environmental influence) creates a perfect storm for a medication error.

Conducting a root cause analysis helps identify underlying systemic issues rather than placing blame on individuals. For example, this analysis might reveal that a hospital’s shift scheduling leads to nurse fatigue or that the electronic health record system is not user-friendly, necessitating redesigns to prevent future errors.

Propose one or more quality improvement strategies that would accomplish both of the following objectives: detect the error when or before it occurs and prevent the error from resulting in patient harm

Proposing Quality Improvement Strategies

For this segment of Module Two Assignment, we will propose quality improvement strategies.

• Suggest methods or tools to identify the error early.
• Consider technologies (e.g., electronic health records, automated alerts) and process changes (e.g., double-checking procedures).
• Propose interventions to mitigate the impact if the error occurs.
• Strategies might include staff training, revised protocols, and safety barriers.
• Use best practice guidelines from reputable sources (e.g., Joint Commission, WHO).
• Ensure your strategies are evidence-based and feasible.

Example

To address medication errors effectively, it is crucial to implement quality improvement strategies that can detect errors early and prevent patient harm. One effective method is using advanced technologies like electronic health records (EHRs) with built-in medication verification systems. These systems can flag potential errors, such as incorrect dosages, before they reach the patient.

Automated alerts can also play a significant role. For instance, if a prescribed medication interacts adversely with another drug the patient takes, a computerized alert can notify the healthcare provider, allowing immediate correction. Process changes, such as implementing double-check procedures where two healthcare professionals verify medication orders, can further reduce the likelihood of errors.

In addition to detection, interventions to mitigate the impact of errors are essential. Staff training programs focused on medication safety can enhance awareness and competence among healthcare workers. Revised protocols, such as standardized medication administration procedures, can minimize variability and reduce errors.

Best practice guidelines from reputable sources, such as the Joint Commission and the World Health Organization (WHO), provide evidence-based strategies for improving medication safety. For instance, the Joint Commission’s “Do Not Use” list of abbreviations helps prevent misinterpretation of medication orders. They ensure these feasible strategies involve regularly monitoring and adapting them based on feedback and outcomes.

Closing

In the MGMT 415 Module 2 Assignment: To Err is Human, you have explored a healthcare error, analyzed its causes, and proposed strategies to improve patient safety. The key takeaways include understanding the multifaceted nature of healthcare errors, the importance of systemic solutions, and implementing proactive quality improvement measures. Following this How-To Owlisdom Guide, students will be well-equipped to contribute to enhancing healthcare quality and patient safety in their professional practice. The upcoming module will improve your understanding of Evidence-Based Practice and PDSA.