Medications and the Culture of Safety

Abstract

Medication mishaps are a common cause of morbidity and mortality both within and outside of hospitals. While the use of a variety of technologies and techniques have promised to improve these statistics, instead of eliminating errors, new ones have appeared as quickly as old ones have been improved. To truly improve safety across the entire enterprise, we must ensure that we create a culture that is willing to accept that errors occur in normal course of operation to the best of people. Focus must not be on punishment and shame, but rather building a fault tolerant system that maintains safety of both staff and patients.

Learning How to Smartly and Adaptively Manage High Functioning Safety Cultures in US Healthcare Organizations During COVID-19

“…Errors arise from poor technique and inadequate knowledge, and human factors, including workplace fatigue, perception failures, and misjudgments (Burrell et al, 2019). Quantifying the magnitudeofharmfulincidentsandengaginginbehaviorsiscriticaltoreducingerrorsandbeing ethicalandhonestwhenengagingpatientsandmakingerrors (Burrelletal.,2019).Thehealthcare cultureunderstandablyfocusesoncaringforpatients,evenattheexpenseofsecurityandsafety (Martin etal.,2017).Thereisacomplextensionaroundethicsandsafetyconcerningpatients'interests,the interestsofthehealthcareorganization,andtheinterestsoffindingquickerpathstotreatingpatients (Hemphill,2015).Theethicalchallengeistheneed,tobehonestwhenpatientsareimpactedby avoidable actions, errors, and unsafe behaviors (Hemphill, 2015). The threat of legal action and expensivepaymentscancreateaculturethatdissuades divulging knowledgeabout mistakes and ethicalviolations (Hemphill,2015;Burrelletal.,2019).Changesinorganizationalculturearecritical toreducingerrorsandmedicalerrorswiththepropensitytoharm (Hemphill,2015).…”

“…Asafeculturedoesnotpunishthosethatdiscoversafetyproblems (Hemphill,2015).Itincludes many mechanisms to report unethical and unsafe organizational practices that can harm patients (Hemphill,2015).Perpetuatingcultureswiththesekindsofmeasuresimprovesafetyandthequality of care (Hemphill, 2015). Unauthorized releases of medical information, poorly given discharge instructions,theabsenceofcoordinatedcarebetweenvariousclinicians,medicationdispensingerrors, andsurgicalmistakesareissuesthatcanoccurinhealthcaresettings (Hemphill,2015).Theutilization ofinnovativehealthcaretechnologiesandsystemshasbeendevelopedtoimprovehealthcaredelivery andthetreatmentofpatients.Oneunintendedconsequencehasbeennewrisksaroundsafetydueto technicalflaws,operatingerrors,andnewcomplexities (Hemphill,2015).Culturesthatareethical, transparent, tolerant, and constructively responsive to human mistakes are critical to developing healthcareculturesthatwillbesafer (Hemphill,2015).Theresultisbuildingsystemswhereblame, severepunishment,cover-upsarechosentoimprovepatientsafety (Hemphill,2015).…”

“…Unauthorized releases of medical information, poorly given discharge instructions,theabsenceofcoordinatedcarebetweenvariousclinicians,medicationdispensingerrors, andsurgicalmistakesareissuesthatcanoccurinhealthcaresettings (Hemphill,2015).Theutilization ofinnovativehealthcaretechnologiesandsystemshasbeendevelopedtoimprovehealthcaredelivery andthetreatmentofpatients.Oneunintendedconsequencehasbeennewrisksaroundsafetydueto technicalflaws,operatingerrors,andnewcomplexities (Hemphill,2015).Culturesthatareethical, transparent, tolerant, and constructively responsive to human mistakes are critical to developing healthcareculturesthatwillbesafer (Hemphill,2015).Theresultisbuildingsystemswhereblame, severepunishment,cover-upsarechosentoimprovepatientsafety (Hemphill,2015). Hemphill (2015) outlines how healthcare mishaps can be observable as poor operational processes, poorly constructed business practices, outdated procedures, poor decision making, flawed organizational structures, equipment malfunction, and human error that could be or even unintentional.Alltheseissuesareevenmagnifiedoraddressedbyhumanresourcesandexecutive leadership'sinterventions (Burrelletal.,2019).Asaresult,itbecomescrucialforleadershiptodrive andperpetuateculturesguidedbyethicaldecision-makingandopenhonestcommunicationwhen therearemedicalerrorsandunsafepractices (Burrelletal.,2019).…”

Cultura de segurança no contexto das organizações de saúde: revisão integrativa

“…Assim, reflete-se acerca da importância da cultura de segurança das organizações de saúde para a redução da incidência de eventos adversos que são potencialmente prejudiciais para pacientes, funcionários e instituição. Enfatiza-se a necessidade do desenvolvimento de equipes assistenciais que estejam dispostas e preparadas a admitir os erros e explorar de forma saudável os obstáculos que envolvem a implementação das práticas seguras, antes que as consequências de um erro cheguem ao paciente (Hemphill, 2015).…”

“…Esta reflexão converge com os estudos já mencionados reafirmando a necessidade de estimular os seres humanos a formar pensamento crítico, reflexivo bem como a autonomia para expressar e discutir, nos espaços organizacionais, democraticamente os erros que porventura venham a acontecer (Fassarella et al, 2018;Hemphill, 2015).…”