Theories of Accident Causation
Reports of medical errors, whether minor or major, are frightening for all involved, but none more than for the person on the receiving end of a mistake. When 17-year old Jésica Santillan received the heart and lungs of a donor who was not her blood type, Duke University Medical Center attempted to correct the error with re-implantation. Unfortunately, the young girl died two weeks later. An investigation found the medical team had inexplicably failed to check for blood type compatibility before surgery began (Duke Medicine News and Communications, 2004). Certainly, the blame initially centered on the person approach; however, that is too simple, as there were layers of people and procedures that obviously failed. …show more content…
Nonetheless, patients are not as safe as they should be, as accidents, errors, and deaths continue to occur, despite continued improvements. According to the Leapfrog Group (2013), hospital errors harm up to 440,000 people annually, and of those harmed, 180,000 die because of preventable errors. This figure is analogous to a jet crashing every day and killing everyone aboard. Often left out of the discussion of patient safety is involving the patients themselves in the effort to reduce errors. The Joint Commission (2014) urges patients to become a self-advocate in its Speak Up™ program. This program recommends organizations train patients to ask questions, pay attention to the care they are given, become educated about their illness, and involve a family member or friend to be an additional patient advocate during a hospitalization. Reason (2000), dismisses the person approach of reducing errors, as effective risk management depends on a reporting culture, which is less likely when fear of reprisal is the expected response. Instead, for maximum exposure and closing of the Swiss cheese holes, the system approach is multi-dimensional, involving the person, the team, the task, the workplace, and the institution as a
Reports of medical errors, whether minor or major, are frightening for all involved, but none more than for the person on the receiving end of a mistake. When 17-year old Jésica Santillan received the heart and lungs of a donor who was not her blood type, Duke University Medical Center attempted to correct the error with re-implantation. Unfortunately, the young girl died two weeks later. An investigation found the medical team had inexplicably failed to check for blood type compatibility before surgery began (Duke Medicine News and Communications, 2004). Certainly, the blame initially centered on the person approach; however, that is too simple, as there were layers of people and procedures that obviously failed. …show more content…
Nonetheless, patients are not as safe as they should be, as accidents, errors, and deaths continue to occur, despite continued improvements. According to the Leapfrog Group (2013), hospital errors harm up to 440,000 people annually, and of those harmed, 180,000 die because of preventable errors. This figure is analogous to a jet crashing every day and killing everyone aboard. Often left out of the discussion of patient safety is involving the patients themselves in the effort to reduce errors. The Joint Commission (2014) urges patients to become a self-advocate in its Speak Up™ program. This program recommends organizations train patients to ask questions, pay attention to the care they are given, become educated about their illness, and involve a family member or friend to be an additional patient advocate during a hospitalization. Reason (2000), dismisses the person approach of reducing errors, as effective risk management depends on a reporting culture, which is less likely when fear of reprisal is the expected response. Instead, for maximum exposure and closing of the Swiss cheese holes, the system approach is multi-dimensional, involving the person, the team, the task, the workplace, and the institution as a