Читать книгу Kelly Vana's Nursing Leadership and Management - Группа авторов - Страница 215

Reluctance to simplify motivates an organization to understand errors. Nurses in HRO health care facilities focus on drilling down to determine the true cause of error. They challenge the current situation to make health care processes and structures safer. For example, a nurse may fail to check a patient's blood sugar as ordered. Initially, the nurse may just indicate “I forgot.” However, analyzing the situation for contributing factors to this failure helps the organization to find real, root cause, and develop solutions. Multiple factors could have contributed to the failure to check a patient's blood sugar. The patient may have been off the unit for a test. The information may not have been shared at change of shift, or a reminder prompt in the electronic health record (EHR) may have been missing. The necessary supplies and equipment may not have been available. An examination of each of these factors allows an HRO to determine ways to prevent this error.

Reluctance to simplify also requires taking action to eliminate work=arounds, the use of short cuts to streamline care without realizing the potential impact on safety. For example, a national patient safety goal requires the use of hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Nurses may save time by rinsing rather than thoroughly washing their hands. Unfortunately, this increases risk to patients and staff. Leaders in HROs identify and extinguish these types of work‐arounds.