POTENTIAL ERRORSSeveral approaches have been developed at UPMC to address the identified risk factors underlying medical errors. For instance, programs have been implemented to educate caregivers in areas such as how to diagnose respiratory distress and delirium. Appropriate training is provided as needed, such as guiding transport personnel to monitor oxygen delivery systems. UPMC has also developed best-practice protocols for various diseases, set criteria for escalation, provided ready access to computerized patient data, standardized treatment policies, and instituted risk-reduction teams to assist in areas where known problems exist, such as the performance of bedside tracheostomies.

HOW TO ENSURE THAT ERRORS DO NOT RECUR

Despite our own best efforts, we must assume that even with policies and procedures in place to prevent the recurrence of medical mistakes, certain errors are likely to happen repeatedly. To address this issue, we have implemented an auditing system to discover more about the repetitive nature of these errors so that we can identify effective system-based changes to reduce their frequency. canada pharmacy mall

Having an organization in place within the hospital to examine past errors, to troubleshoot inadequate policies, to revise guidelines, to provide opportunities for supplementary education, and to monitor one-time and recurring errors is essential for achieving maximum patient safety. Achieving the goal of universal nonpunitive reporting requires the investigation of adverse events in real time, so that the importance of the event is stressed. Only then will the need to improve the processes of care become ingrained in the care-givers who participate in these activities. Thus, positive changes in the culture can be achieved and the adverse outcomes caused by problems inherent in the care system itself can be reduced.