In the spotlight comes the gaps again in hospitals After all, the incident of the wrong transfusion to the Tzanio Hospital.
Hospital mistakes are not exceptions, but predictable consequences of a framework that has been significantly “gaps” and has been around for years.
Nursing professors Petros Galanis and Ioannis Mosoglou record the deepest causes of inevitable errors in nursing care, which starts with the exhaustion of nurses and reaches the systemic failure of prevention.
The safety of health care to patients is one of the most important dimensions of quality in the field of health. US National Academy of Medicine defines the safety of health services as “avoiding patients in patients during health care”.
Damages occurring in patients during their hospitalization, as well as their investigation to improve health services are not a new phenomenon in health systems.
As early as the early 20th century errors were recorded and notified. The notification of errors was used as a learning tool in order to improve their performance.
However, patient safety was at the heart of much later, when in 2000 the US National Academy of Medicine published its report entitled “To Err Is Human: Building a Safer Health System”.
It stated that about 100,000 patients were killed in the US annually in the US during hospitals due to mistakes in their care. This number was larger than those who died in total every year from traffic accidents, breast cancer or AIDS. This report has shocking health systems, and now the safety of health services has begun to be a priority internationally.
Despite the constant efforts, patients’ damage, known as adverse events, due to mistakes in their care continue to be a constant threat to patients.
Errors in medicationinfections, surgical trauma infections, falls, pulmonary embolism, abstracts, postoperative hemorrhage and postoperative sepsis are just some of the adverse events that patients can experience during their hospitalization.
According to the European Center for Prevention and Infectious Diseases (ECDC), it is estimated that more than 3.5 million hospital infections are recorded annually in the European Union, leading to more than 90,000 deaths and corresponding to about 2.5 million lost years of disability (DALYS). The effects of these adverse events include the death of patients, their permanent or transient disability and the increase in duration and cost of hospitalization.
It is estimated that the 10-15% of hospitalized patientsexperiences an unfavorable event.
As nurses provide almost 95% of the care that patients receive during their hospitalization, they are the ones who significantly affect patients’ safety.
The way in which the nurses’ work environment is organized and managed is associated with the appearance of adverse cases. According to international literature, the Nursingexcessive workload, professional exhaustion, circular working hours, leadership style and the small ratio of nurses/patients are related to the appearance of adverse events.
In terms of nursing staffing in hospitals and patient safety, both numerical staffing and qualitative characteristics of nursing staff, such as educational level, service, contractual nurses and postgraduate studies, play an important role.
What do Greek nursing staff studies prove in our country
Studies in Greece have shown that the working environment of nurses is characterized as poor. Specifically, the findings of the studies show that:
- Nursing staff are experiencing very high rates of exhaustion and dissatisfaction from his work,
- works in under -staffed sections with many night shifts and
- With limited resources and nursing processes of quality.
A phenomenon that now becomes large internationally in all areas of labor is that of silent retirement, where the employee does not resign from his job, but remains and reduces his effort, provides the few services in order not to be fired, does not participate in discussions with his colleagues.
This work behavior has been studied with nursing staff in Greece and more than 60% experience high levels of tacit retirement precisely because it has been professionally exhausted and is not satisfied with their work. In this context, implicit departure is another factor that can lead to reduced productivity and degradation of the quality of health services provided.
The constant improvement of the quality of health services, and of course patient safety, is a constant and systematic effort and is characteristic of modern health systems.
The two conditions for safe care of nursing care
According to the model proposed by the Avedis doanbediana pioneer researcher in quality, evaluation and thus ensuring the quality outcome of care depends on two important variables.
The first variable is the resources of the system and in particular the human resources. Without sufficient staffing, with high training and experience we cannot have quality health services. Health systems are now facing significant challenges (patient safety) and resemble high -speed vehicles in an ever -changing environment (increase in chronic diseases, population aging, pandemics). We cannot continue to be in place of the driver of a Formula 1 car, the driver of a tractor and expect that we will finish first.
The next variable proposed by Donabedian is the existence of processes that can include policies, diagnosis, treatment and nursing care protocols, certifications and credentials, the way leadership exercise, risk, recording and investigating adverse events. According to Edward Deming, a distinguished academic and teacher in the American academic community, 85% of the causes of failure are due to systems and processes rather than employees. The role of the administration is to change the processes and not to push people to do a better job.
Providing nursing care (drug administration, blood transfusion) is a complex procedure that could be similar to the movement of a vehicle into a busy avenue. It is not just enough for the driver to have a driving license and a driving experience to reach the end of the Avenue safely. The happy end of the journey may depend on the speed of other vehicles, the driving behavior of other drivers, the lighting and the road marking, the vehicle’s condition and the driver’s fatigue. The fact that some drivers in the end are safely reaching the end safely does not ensure that all drivers achieve the same result and without delay.
The death of a patient is the ‘top of the iceberg’
When an unfavorable event has a bad outcome (eg the patient’s death), then this event we see is what is described in the literature as the tip of the iceberg.
Certainly before this serious incident, there have been many less serious incidents. If we stay inactive against these small incidents, we stigmatize the one involved and choosing witch hunting, then we have just taken a stand and we are waiting for the tip of the iceberg again.
Despite interventions, adverse events continue to occur in all health systems internationally. Therefore, the next step in an ever -improving health system is Management of errors and adverse events.
The first reaction must be the investigation of the conditions in which the mistake that led to an unfavorable event took place. Tools such as Root Cause Analysis and Fishbone help to highlight the complex conditions and causes that have led to the unfavorable event. Still, the mistake should be treated as a reason for learning, and not the cause of stigmatization, in a context of a fair culture. The exploitation of learning error is a component of the health security culture.
Improving the quality and safety of care is, of course, a complex process. As mentioned above, the approach to improving the quality and safety of care should not start the opposite, that is, by focusing only on care outcomes, but must begin and based on resource safeguarding and the introduction of procedures, the use of proper staff and the creation of proper staff.
In conclusion, mistakes in health services as well as any other work environment are inevitable. The point is to form the appropriate framework and procedures so that these errors are constantly reduced and limited to the lesser extent possible. The formation and implementation of appropriate insurance forms in the processes in a hospital is the most decisive parameter for the reduction of mistakes.
Petros Galanis, Associate Professor, Department of Nursing, National and Kapodistrian University of Athens
Ioannis Mosoglou, Assistant Professor, Department of Nursing, University of Thessaly
Source: iatropedia.gr