Читать книгу Kelly Vana's Nursing Leadership and Management - Группа авторов - Страница 303

1 What factors may have contributed to the original error?

2 Why was an interprofessional team convened for the root cause analysis?

3 What factors may have contributed to a second error in the pediatric department?

4 Both human factors and organizational factors may have contributed to this error. The nurse may have been fatigued or rushed. She may not have treated the breast milk like a medication, and may not have checked the table three times. The nurse may have experienced confirmation bias, seeing what she expected to see. The nurse may have read the label correctly but reached for the wrong container. The label may have been handwritten and difficult to read. The room may have been poorly lit, making it difficult to read the label. Breast milk storage may not have been individualized for each patient, making it easy to grab the wrong container. The organization may not have invested in bar code scanning technology.

5 Although on the surface this appears to be a simple nursing error, as seen above, many factors may have contributed to the error. All stakeholders should be involved in a root cause analysis to provide a broad perspective and create the most effective plan for preventing the error in the future.

6 Organizational culture, communication, and human factors may allow the same error to occur in different areas within the same organization. If an organization lacks transparency, lessons learned from errors in one area are not shared with other areas. They are kept “secret.” Even if an organization aspires to transparency, communication must be clear, concise, and targeted so that the information is received and perceived to be important by the clinicians who may be affected. Nurses and other clinicians must realize they, too, are vulnerable to making errors. The attitude of “I would never make that mistake” needs to be expunged.