Patient safety risks are the circumstances that may compromise the safety of patients in any given situation. It is an issue that has proven to draw many peoples’ concerns. Therefore, the various healthcare centers have tried to work towards reducing and preventing the patient-related risks. For instance, there has been the application of improved systems, such as the healthcare technology. This write-up, therefore, identifies and discusses misdiagnosis as a patient safety risk. It also analyzes the influence of systems’ errors and human factors with regard to this risk. Additionally, it discusses the related insights that could be gained from the high-reliability organizations and their possible application within a healthcare organization. Finally, it proposes strategies and tools for assessing and reducing risks related to the safety issue and describes how patients and their families can be involved in addressing this issue.
According to the Joint Commission (2009), healthcare organizations are the institutions that provide medical services and care for patients with such diseases and disorders as Down syndrome, cancer, pediatric patients, mental illness and so on. However, these healthcare institutions are noted to be prone to patient safety risks, situations that may put patients into further poor health conditions in the course of their medication and care by health care attendants. The most common risks to patients’ safety include: patient falls, misdiagnosis, delayed treatment and so on. However, they vary in different healthcare settings or with different patients. This is because the different healthcare centers may be dealing with different patients’ conditions. Equally, they may also be having different infrastructural settings (Joint Commission, 2010).
Among these safety risks, misdiagnosis of a patient is the most serious risk to the patients’ safety. It is the situation whereby a patient’s health condition is wrongly perceived by the health specialist, hence, giving inappropriate treatment and care to such a patient. It, therefore, deserves a particular attention since it may lead to further health complications such as worsening the already existing problem, or simply the patient may not respond to the treatment given. Therefore, the health specialists should be very much careful when diagnosing patients (Hitchings, Davies-Hathen, Capuano, Morgan, & Bendekovits, 2008).
This risk may be the result of either or both the systems error and human errors. Generally, the healthcare error is defined as any preventable adverse effect of care. The systems error may be the failure of the automated health systems such as machines and other gadgets to deliver the exact report regarding the patients’ health status (Pronovost, Rosenstein, Pain, & Miller, 2008). Poor communication may also be part of the systems’ error and it may equally lead to misdiagnosis of a patient. On the other hand, the human errors are the errors which come about as a result of misanalysis of the data about the patients’ health by the physicians (Wu, Lipzhutz & Pronovost, 2008). It may be because of insufficient training and experience, fatigue, time pressures or unfamiliar settings by the physicians. In certain cases, it may also be caused by patients when they fail to give the exact information to the medical practitioners when asked (Reason, 1990).
In order to deal with the systems risks, the healthcare centers should always ensure that the machines and the other gadgets used to diagnose the patients` illness are in proper conditions to provide the exact results. On the other hand, prevention of human errors involves the proper training of the healthcare givers so that they may be very conversant with the patients` diseases and disorders and their causes. The practitioners should also learn how to use the patients’ checklist so that they do not confuse the patients’ respective information. Additionally, institutional policies should be put into place in order to ensure that the physicians’ decisions are properly guided. Moreover, those patients who are not in position to state whatever they feel should always have trusted substitute decision makers who can talk on their behalf with the medics (Laurance, 2009).
Currently, healthcare institutions have tried to copy and adopt the concepts applied by the high reliability organizations. These are the organizations that have employed the use of very effective systems. However, most of these organizations are the ones which are faced with the adverse problems in cases of any slight error or mistake. They include the air craft industry, the stock exchange markets, and the legal firms. Their concepts of operations can therefore be applied in healthcare institutions, but in different contexts. First, they are very sensitive to the operational changes. This means that they recognize that the systems and policies normally change and so they are very mindful of the complexities in which they work, so they are quick to identify the problems in the systems and to rectify them. The healthcare centers can also employ the use of this tactic in evaluating systems and making the necessary changes and adjustments to them (Grol, 2001).
Secondly, these organizations are very reluctant to simplify their present problems. This means that they do not ignore any problem they face. The healthcare institutions may also employ this by being consistent in carrying out researches on the various problems that they deal with, so that they are ever prompt in tackling them. Additionally, such organizations are also focused on predicting and eliminating the future catastrophes rather than just waiting for them to happen, so they can react when they occur. The healthcare organizations can, therefore, copy this by ensuring that they put up operational systems which can regularly evaluate and ascertain that their systems are in order. This would help to avoid future errors and problems (Guyatt, Cairns & Churchill, 1992).
It is further noted that these organizations employ the use of the experts in order to assist them in solving the problems within the organizations. The healthcare organizations, on the other hand, can emulate this by ensuring that in case of diagnosis problems, the more qualified experts are contacted. They should also employ the engineering experts who can continuously conduct proper maintenance for the diagnosis-aided machines. Finally, these organizations are also characterized by a high degree of demonstration of resilience. This means that they don’t give up once an error has occurred. Instead, they try very hard in order to contain and fix them. This can be also possible with the healthcare centers. For instance, they can strategize in order to always have alternative courses of actions whenever an emergency occurs (Bosk, Dixon-Woods, Goeschel & Pronovost 2009).
Apart from the application of the high reliability organizations concepts, the healthcare organizations should come up with strategies and tools which can help them assess and reduce the risks associated with the misdiagnosis problem. For instance, they can employ the use of Health Information Technology (HIT) in order to help them in monitoring the systems. This is to ensure that the systems being used for diagnosis are in the proper condition (Gawande, 2009). The healthcare centers should also employ the use of quality improvement methodologies which range from total quality management to continuous quality improvement by the use of the Six Sigma. The Six Sigma is appropriate since it emphasizes the definition of goals, measure of the process capabilities, analysis of alternatives, and design of operation details (Commission, 2009).
In addressing the issue of misdiagnosis, both the patients and their families should be involved. For instance, the patient should be made aware of the consequences of giving wrong information to the physicians in the course of diagnosis. They should be encouraged by the physicians to always report their health progress and general feelings in order to assist in choosing the kind of care and medication that should be given to them in the course of their recovery. On the other hand, the patients` families can be also involved in the process in various ways.
First, they should be asked to provide the patient`s health background so as to assist in the diagnosis process. They should be also ready to assist with substitute decision making in cases where the patient is not in position to make decisions (Oakbrook & American Hospital Association, 2003). Finally they should be enlightened by the physicians on the type of care which should be given to the patients and then be encouraged to do so for the patients at home (Oakbrook & American Hospital Association, 2003).
In conclusion, patient safety is a very important issue that should be of concern to every health care giver and, therefore, they should work towards improving it.