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| title | chunk | source | category | tags | date_saved | instance |
|---|---|---|---|---|---|---|
| Patient safety | 3/10 | https://en.wikipedia.org/wiki/Patient_safety | reference | science, encyclopedia | 2026-05-05T04:26:13.019610+00:00 | kb-cron |
The simplest definition of a healthcare error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Errors have been, in part, and/or attributed to:
=== Human factors === Variations in healthcare provider training and experience, fatigue, depression and burnout. Diverse patients, unfamiliar settings, and time pressures. Failure to acknowledge the prevalence and seriousness of medical errors. Increasing working hours of healthcare personnel. Mislabeling specimen or forgetting to label specimen. States of anxiety and stress put on the healthcare provider.
=== Medical complexity === Complicated technologies, powerful drugs. Intensive care, prolonged hospital stays.
=== System failures === Unsafe communication. Unclear lines of authority or guidelines for physicians, nurses, and other care providers. Complication increasing when the patient to nurse staffing ratio increases to a point where the patient rate is higher than the rate of staff. Disconnected reporting systems within a hospital: fragmented systems in which numerous hand-offs of patients result in errors in examples such as coordination or other general reports due to even minor errors. Drug names that look alike or sound alike. The impression that action is being taken by other groups within the institution. Reliance on automated systems to prevent error. Inadequate systems to share information about errors hamper analysis of contributory causes and improvement strategies. Cost-cutting measures by hospitals in response to reimbursement cutbacks. Environment and design factors. In emergencies, patient care may be rendered in areas poorly suited for safe monitoring. The American Institute of Architects has identified concerns for the safe design and construction of healthcare facilities. Infrastructure failure. According to the WHO, around 50% of medical equipment in developing countries is only partly usable due to a lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment. The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, between providers and the patient, and between providers and the patient's family members, was the root cause of over half the serious severe adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, poor leadership, and/or training. Common misconceptions about adverse events are:
" 'Bad apples', or incompetent health care providers are a common cause for patient harm". Many of the errors are normal human slips or lapses, and not the result of poor judgment or recklessness. "High-risk procedures or medical specialties are responsible for most avoidable adverse events". Although some mistakes, such as those in surgery, are easier to notice, errors occur at all levels of care. Even though complex procedures entail more risk, adverse outcomes are not usually due to error, but to the severity of the condition being treated. However, USP has reported that medication errors during the course of a surgical procedure are three times more likely to cause harm to a patient than those occurring in other types of hospital care. "If a patient experiences an adverse event during the process of care, an error has occurred". Most medical care entails some level of risk, and there can be complications or side effects, even unforeseen ones, from the underlying condition or from the treatment itself.
=== Nursing burnout and patient safety === In the medical field, many things can lead to decreased patient safety. One significant influence on this is nurse burnout, leading to hundreds of thousands of deaths a year and billions of dollars spent when having to rectify a new problem; this is a real issue in the world. On average in the medical field, one out of 20 prescriptions filled contains an error, considering the billions of prescriptions that get filled every year there is a vital amount of error happening. With these errors, not only is there a likelihood of a prescription being wrong, but there is a $3.5 billion price tag that goes with it, covering the amount that people pay each year for litigation costs and extra days that patients need to stay in hospital beds because of mistakes from the hospital. Burnout has been going on for years amongst nurses and other physicians, affecting nearly half of healthcare workers. Burnout has been going on for decades and the term was originally coined by Herbert Freudenberger. Freudenberger was working at a free clinic, and over time mentioned some of the effects that he had seen, such as "emotional depletion and accompanying psychosomatic symptoms... excessive demands on energy, strength, or resources". These burnout symptoms are commonly seen today in hospital settings as nurses feel like they are pushed to the edge. This emotion is not ideal nor wanted for everyone, especially for people who have to look after patients and take care of others who can be in very severe and mortally harmed states. Using what Freudenberger described, there was a scale created to measure the amount of burnout in the healthcare field. Known as Maslach's scale, this measures 1. Workload, 2. Control, 3. Reward, 4. Community, 5. Fairness, and 6. Values. All of these core points work together and the less you have of most of them, the more likely that burnout will occur and cause a major decrease in patient safety. Similarly to Maslach's scale, there is the Conservation of Resources Theory. This theory essentially states that if one of the four pillars are lost, so are safety and control. According to the Journal of Advanced Nursing, "Healthcare organizations and nursing administrations should develop strategies to protect nurses from the threat of resource loss to decreases in nurse burnout, which may improve nurse and patient safety." The amount of nursing professionals that have experienced burnout is said to be around 50%. This number leads to an increased risk of adverse events that should not happen, ranging from 26% to 70% of a higher risk that something negative will happen to the patient.
== Safety programs in industry ==