Errors in the delivery of medical care are the principal cause of inpatient mortality and morbidity, accounting for up to 98,000 deaths annually in the United States of America (USA). The notable report from 1999 "To Err is Human: Building a Safer Health System"1 pioneered patient safety reform within the medical community. In this groundbreaking report, contributing factors were described such as decentralized health care delivery systems and liability concerns. They also established a four-tiered method to improve patient safety by educating, identifying errors, improving standards, and implementing the system. The aim of the report was to evaluate medical care in the United States and improve overall quality of care in the future.1
Ineffective team communication, especially in the operation room (OR), is a major root cause of these errors.2 Miscommunication can be reduced by analyzing and constructing a conceptual model of effective communication in the OR. Mickan et al. described six characteristics of an effective team involving purpose, goals, leadership, communication, cohesion, and mutual respect. Incorporating these qualities into medical communities can minimize errors and improve patient safety.3
No matter what changes health care systems encounter, one concern is constant: ensuring exceptional patient safety and care. Patient safety is ensured by utilizing safety science guidelines to accomplish a reliable and effective health care practice. Establishing educational methods for health care professionals is essential in preventing malpractice and providing the safest care possible. Current systems of patient safety education need revision in order to optimize patient experience. To do so, patient safety systems should focus on building a culture of safety that encourages communication, trust, and honesty.4
It is important to recognize that humans make errors. Failures occur either due to inappropriate methods of care or an improperly executed appropriate method of care. Error can be minimized with proper training, effective communication, and a medical system of checks and balances. Continual education regarding patient safety not only helps health care professionals, but also extends to patient well-being. Concise communication with patients instills trust and strengthens patient-provider relationships. Establishing a medical system of checks and balances ensures that errors are more likely to be caught before they happen and that blame does not rest upon an individual.
Errors are inevitable, but having a system in place to prevent them from occurring, and remedying them when they do occur, improves overall patient safety in the health care environment.
The process to improve patient safety in health care systems is listed below:
- Identify current issues regarding patient safety
- Revise system, education, and training to address patient safety issues found
- Educate health care professionals about the importance of patient safety concepts. Establish medical system of checks and balances to reduce medical error. Practical application of patient safety concepts - training
- Patient interaction utilizing education to reduce errors
Then the process can be repeated to address errors that persist.
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