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Ensuring Patient Safety – The Ultimate Survivor Game – Part 1

This blog post is based on a recent Webinar with HealthStream’s Joseph Caracci, AVP, Clinical Assessments.

Caracci is an RN and has been a thought leader in healthcare for the last 20 years. His extensive clinical, business, and IT experience has made him a well-respected expert and an innovator in helping healthcare organizations provide safe and effective care to patients. In this webinar, Caracci focuses on identifying who is responsible for ensuring patient safety and the main causes of the most frequent medical errors.

Preventing Medical Errors – Who Are the Stakeholders?

Citing Karen Ballard’s article entitled “Patient Safety, A Shared Responsibility,” Caracci identifies the stakeholders in the drive towards improved patient safety. The list is a long one. Ballard includes such diverse people and groups as legislators, society, patients, physicians, professional associations, hospital administrators, nurses, and nurse educators as key stakeholders in the quest for improved patient safety.

While all of the people, professionals, and groups listed above can impact patient safety, Caracci believes that none have more impact than nurses and nurse educators. Caracci says that, “It is crucial to patient safety and a professional responsibility for nurses to remain safe and competent at all times. A nurse’s ability to think critically is essential to patient safety.”

Nursing educators are key to helping nurses to develop the critical thinking that is essential to safe and effective patient care. Caracci is passionate about the role of nurse educators stating that, “nursing educators are in one of the greatest positions to help improve patient care and to develop our future nurses.” 

Medical Errors – Why Do They Still Happen?

Despite the long list of stakeholders, the fact that some sentinel events are 100% preventable, and the fact that medical errors have been in the spotlight for years now, the reported numbers for the top 10 sentinel events for which the Joint Commission has data has remained relatively unchanged over the past few years. How could that be?  Caracci cites the well-respected research conducted by the Lucien Leape Foundation. They report an impressively long list of contributing factors that includes such diverse factors as unsuccessful interactions with technology, staff stress and fatigue, poor staff-to-staff and staff-to-patient communication, and higher levels of patient acuity. While all of these factors are certainly contributory, Caracci has focused on the four factors that can be most directly impacted by nursing and nurse educators.

  • Poor staff-to-patient communication
  • Poor staff-to-staff communication
  • Lack of appropriate education and training
  • The need for rapid decision-making

Caracci encourages nursing leaders to think about each of these causes as a gap that needs to be closed to ensure that no medical errors can “slip through.” This unique way of looking at these contributors helps to inform us on the best strategies to reduce medical errors.

To learn more about Caracci’s recommendations on how nurses and nurse educators can fill these gaps, Part 2 of this blog series will be posted soon.

Listen to the Webinar.

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