Healthcare System Errors

Healthcare system errors have become a crucial challenge in modern medical practice, leading to preventable patient harm, augmenting healthcare costs, and eroding confidence in the same institutions. System errors and medically adverse events to misdiagnosis persist in technologies like electronic health records (EHRs); therefore, solutions would require comprehensive strategies involving technological interventions, adequate staff training, and redesign of processes. These are mistakes that, unless allowed to happen through deficits in the system, will cause the patient outcomes to continue to suffer. This paper argues that a human-centered and technological multi-modal approach is critical to significantly reducing health system errors and improving patient safety.

Professional Relevance and Personal Experience

Healthcare system errors are deeply rooted, with health professionals, nurses, and physicians being the frontiers of service delivery in patient care. Medication administration errors are among the most prevalent and preventable forms; however, they have powerful consequences on patient safety. From my experience in clinical settings, most of these applications emanate from miscommunication, poor physician orders, and incomplete patient information. Added to this is the risk of such mistakes brought about by inefficiencies in the system, including poorly designed workflows and inadequate staffing. Being knowledgeable about these matters is a professional obligation and a prerequisite for providing high-quality care.

Article Selection Process

A thorough search was conducted using academic databases like PubMed, Google Scholar, and CINAHL to find pertinent peer-reviewed literature on healthcare system failures. Keywords such as “healthcare system errors,” “medication errors,” “patient safety,” and “system redesign” were used to refine this search and get references on studies dealing with interventions that minimize errors. Next, filters were used so the results would give peer-reviewed articles from the last 3-5 years. The information obtained must be updated and relevant to today’s health practices. The selected articles for review discuss various ways in which errors in the health care systems could be reduced, integrating technologies into the system, and the need for continuous staff education.

Assessing Credibility of Sources

The CRAAP model was applied to consider the validity of these articles: currency, relevance, authority, accuracy, and purpose. All the sources had to be peer-reviewed to ensure other professionals had critically analyzed the findings. Much emphasis was placed on articles published in the last 3-5 years to ensure the relevance of the information in today’s fast-evolving healthcare environment. Of greater importance, the authority of each was assessed by considering who the authors were, preferably those with extensive experience in managing healthcare, nursing, and patient safety. Each article’s accuracy was considered by discovering its methodology and clarity of results.

Annotated Bibliography

Au, H. D., Kim, D. I., Garrison, R. C., Yu, M., Thompson, G., Fargo, R., Nathaniel, B., Chitsazan, M., Puvvula, L. K., Motabar, A., & Loo, L. K. (2020). Code S: Redesigning hospital-wide peer review processes to identify system errors. Cureus, 12(6). https://doi.org/10.7759/cureus.8466

This article represents implementing a “Code S” initiative, a hospital-wide peer review process for identifying and correcting system errors in healthcare institutions. This is where things take a turn: most traditional peer review processes have revolved around individual clinician performance, while more significant systemic issues are often left unaddressed. “Code S” creates a refocused approach to finding the origins of system failures and a culture of continuous improvement and shared accountability. This redesign discussed in this article presents how improvement in patient safety is guaranteed through the encouragement of the staff to report the errors and to be actively involved in the solutions without fear of blame. The rationale of the article was based on an innovative approach to solving healthcare system errors through redesigning internal review processes. Practical solutions can be adapted usefully across a range of healthcare settings. Therefore, the authors conclude that introducing system-level reviews in the peer review process may drastically reduce errors, improving patient care quality by establishing a culture of transparency and learning.

Dhingra-Kumar, N., Brusaferro, S., & Arnoldo, L. (2021). Patient safety in the world (L. Donaldson, W. Ricciardi, S. Sheridan, & R. Tartaglia, Eds.). PubMed; Springer. https://pubmed.ncbi.nlm.nih.gov/36315756/

This article provides a global perspective on patient safety, focusing on the common causes of patient harm across healthcare systems worldwide. It emphasizes the need for more robust safety protocols and system improvements to reduce errors, particularly in low- and middle-income countries with less-developed healthcare infrastructure. The article also highlights the role of international collaboration in improving patient safety practices, advocating for sharing knowledge and strategies across borders to tackle systemic challenges. Key prevention strategies included standardized safety procedures, training programs, and improved reporting systems. The article was included because it offers a global perspective on patient safety. Indeed, the insight into how systemic errors occur worldwide makes this highly relevant to the researched topic. The authors conclude that, although practical, technological advances merely supplement the work of international cooperation and capacity building in lowering patient safety risks and improving outcomes worldwide.

Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

This article provides an in-depth analysis of causes and types of medical errors within healthcare systems, including medication and diagnostic, and presents strategies for their reduction and prevention. The article underlines the role of systemic interference, including the use of EHRs, which eliminate the possibility of errors in documentation. It points out that improvement is needed in communication among healthcare workers so they do not misinterpret patient information. This article also focuses on developing a safety culture where health professionals can report errors without being subject to punitive measures or reprisals. The approach that makes this article relevant for the research is that it outlines comprehensive and evidence-based ways to handle errors in the healthcare system. The authors conclude that error reduction involves technology, such as EHRs, coupled with organizational changes in improved communication and a supportive error-reporting culture capable of yielding significant improvements in patient safety and outcomes.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2023). Medication dispensing errors and prevention. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30085607/

This article analyzes medication dispensing errors that plague healthcare systems and the steps that ought to be taken to avoid them. It further reviews different types of dispensing errors, such as dosing errors, wrong drug errors, and labeling/misidentification errors, concerning human factors, including fatigue and communication failure. Additionally, the article focuses on prevention measures such as automatic medication dispensing, barcodes, and enhanced knowledge about the dangers of medical mistakes among workers. The authors also propose increasing safety culture, which would protect healthcare workers from reporting cases of dispensing errors without facing disciplinary measures. The rationale for including this article is its provision of a rich understanding of medication dispensing errors, a significant category of healthcare system errors, thereby considering it highly pertinent to the endeavor. The article summarizes the studies by arguing that technology integrated with staff education and a supportive reporting culture helps reduce dispensing errors and enhance patient safety.

Summary of Learning

In doing this research, I realized that healthcare system errors are not simple and require multiple approaches to minimize. It is thus crucial to ensure that errors are reduced. Technology solutions form part of the solution, while human solutions like staff awareness and workflow enhancements are also essential. Root causes and human factors are part of the system, so a comprehensive approach is needed to manage healthcare errors. This integrated approach not only affords the patient safety they require but also amounts to a more practical approach to healthcare delivery.

References

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2023). Medication dispensing errors and prevention. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30085607/

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Question

Healthcare System Errors

Assessment 2: Applying Research Skills
Instructions
Create a 3-5 page annotated bibliography and summary based on your research related to best practices addressing a current health care problem or issue.

Introduction
In your professional life, you will need to find credible evidence to support your decisions and your plans of action. You will want to keep abreast of best practices to help your organization adapt to the ever-changing health care environment. Being adept at research will help you find the information you need. For this assessment, you will research a health care problem or issue faced by current health care organizations.Instructions
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure to address each point. In addition, you are encouraged to review the performance-level descriptions for each criterion to see how your work will be assessed.For this assessment, research best practices related to a current health care problem. Your selected problem or issue will be utilized again in Assessment 4. To explore your chosen topic, you should use the first two steps of the Socratic Problem-Solving Approach to aid your critical thinking.

Select one of the health care problems or issues presented in the Assessment 02 Supplement: Applying Research Skills [PDF] resource. Write a brief overview of the selected health care problem or issue (Healthcare System Errors). In your overview:
- Summarize the health care problem or issue.
- Describe the professional relevance of this topic.
- Describe any professional experience you have with this topic.
Identify peer-reviewed articles relevant to this health care issue or problem.
- Conduct a search for scholarly or academic peer-reviewed literature related to the topic and describe the criteria you used to search for articles, including the names of the databases you used. You will select four current scholarly or academic peer-reviewed journal articles published during the past 3–5 years that relate to your topic.
- Refer to the NHS-FPX4000: Developing a Health Care Perspective Library Guide to help you locate appropriate references.
- Use keywords related to the health care problem or issue you are researching to select relevant articles.
Assess the credibility and explain relevance of the information sources you find.
- Determine if the source is from an academic peer-reviewed journal.
- Determine if the publication is current.
- Determine if information in the academic peer-reviewed journal article is still relevant.
Analyze academic peer-reviewed journal articles using the annotated bibliography organizational format. Provide a rationale for inclusion of each selected article. The purpose of an annotated bibliography is to document a list of references along with key information about each one. The detail about the reference is the annotation. Developing this annotated bibliography will create a foundation of knowledge about the selected topic. In your annotated bibliography:
- Identify the purpose of the article.
- Summarize the information.
- Provide rationale for inclusion of each article.
- Include the conclusions and findings of the article.
- Write your annotated bibliography in a paragraph form. The annotated bibliography should be approximately 150 words (1–3 paragraphs) in length.
- List the full reference for the source in APA format (author, date, title, publisher, et cetera) and use APA format for the annotated bibliography.
- Make sure the references are listed in alphabetical order, are double-spaced, and use hanging indents.
Summarize what you have learned while developing an annotated bibliography.
- Summarize what you learned from your research in a separate paragraph or two at the end of the paper.
- List the main points you learned from your research.
- Summarize the main contributions of the sources you chose and how they enhanced your knowledge about the topic or issue.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

Assessment 2 Example [PDF] (Attached).
Healthcare System Errors

Additional Requirements
Your assessment should also meet the following requirements:

Length: 3–5 typed, double-spaced pages, not including the title page and reference page.
Font and font size: Times New Roman, 12 point.
APA tutorial: Use the APA Style Paper Tutorial [DOCX] for guidance.
Written communication: Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
Content: Provide a title page and reference page following APA style.
References: Use at least four scholarly or academic peer-reviewed journal articles.
APA format: Follow current APA guidelines for in-text citation of outside sources in the body of your paper and also on the reference page.

Healthcare System Errors

Healthcare System Errors

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