Building in safeguards that make continued pressure on organizational
error less likely or recovery more
possible make tightly coupled
processes, such as medication
administration and surgical
procedures, more reliable (Kohn,
Corrigan, and Donaldson 2000). The
Joint Commission on Accreditation of
Healthcare Organizations’s (JCAHO)
protocol for preventing wrong-site
surgery involves marking the surgical
site, involving the patient in the
marking process, and taking a final
“time out” in the operating room to
double check information with all
members of the surgical team (JCAHO
2003).
RECONCILING THE
SYSTEM AND HUMAN
CAUSES OF ERROR
The concept of the systems approach
to viewing error should be reconciled
with the more pervasive view of
individual responsibility. Complex
systems can break down at many
points as the result of latent and
active failures (see Figure 1 on the
following page) (Reason 1990, 202).
Role of Fallible Decisions
The origin of many errors is fallible
decisions. In healthcare, the
finances has led to a number of faulty
choices that affect employees and
resources. These include curtailing
overtime and agency use, reducing
staff, substituting registered nurses
with less-skilled employees, and
deferring equipment upgrades. Often
the results of such changes are
readily visible in the next quarter’s
financial statements, but the effects
on patient safety and healthcare
outcomes are more subtle.
The incidence of nosocomial
infections may increase, lengths of
stay may rise, more patients may
suffer from decubitus ulcers, and
medication errors may be more
frequent. But these occurrences may
not appear on management’s radar
screen until they reach significant
levels or lead to a major adverse
outcome. In fact, the news of
improved financial performance may
reinforce fallible strategies and push
patient safety initiatives further into
the background.
Impact of Middle Management
Middle managers have a great deal to
do with the quality of staff recruited
and retained, the degree to which
policies and procedures are
implemented, the types of activities
emphasized and rewarded, and the
MEDICAL ERROR | 09