Medical Error Reporting – Policy and Procedures
Policy Title: Management of Medical Errors Policy
As a new free-standing hospital, the recognition and reporting of medical errors are essential in the improvement of quality service delivery. Due to the high prevalence rates of medical errors in the Saudi Arabian Kingdom, a comprehensive assessment policy will facilitate both voluntary and mandatory medical incident reporting, including the circumstances and context. This will ensure that patient safety is guaranteed and the healthcare providers are protected from psychological disturbance that may result from the adverse impacts of identifiable medical errors, such as patient death. The occurrence and context of errors will be evaluated through root cause analysis and a Critical Incident Reflective Exercise established as a formal way of assisting the staff to learn from clinical incidents. Nurse Managers will be responsible for the implementation of the Critical Incident Reflective Exercise to encourage voluntary reporting and mentor the staff in evidence-based practice.
The Institute of Medicine (IOM) defined medical errors as a failure in the completion of planned clinical actions or the use of a wrong plan with similar objectives, which compromises patient safety (Rodziewicz & Hipskind, 2019). This policy will enhance the consistency in evidence-based practice through the enforcement of a culture of justice and fairness in the occurrence of adverse clinical incidents, including careful investigation, self-reporting, and learning. This policy will also provide a framework for health practitioners to enhance practice and empower the managers to take appropriate actions without bias. The establishment of a culture of responsibility and consistent reporting of medical errors will protect patient safety and enhance daily clinical practices for the improvement of health outcomes. The reporting of health care errors can be verbal, written, or through a reporting system, such as emails or web-based communication. This institution recognizes the clinicians’ fear of lawsuits resulting from the communication of errors to patients and their families, in addition to self-perceived incompetence that could be spurred by a culture of blame. Reporting medical errors, including near misses and patient safety events, is critical in the prevention of future errors and thus, this policy is emphatic on the culture of accountability and patient safety.
This policy applies to all healthcare and medical staff, including (but not limited to) registered nursing associates, doctors, nurses, paramedics, pharmacists, emergency care practitioners, and allied health care professionals. This policy also applies to pre-registered healthcare professional students involved in medical processes under direct supervision, such as medical, nursing, and allied health care students. This policy hereby states that the involvement of students in a medical error will require direct reporting and engagement of their respective educational institutions. Healthcare managers will be responsible for implementing this policy and promoting a culture of accountability through continuous evaluation of daily practices and procedures, and review of all reported medical errors as a learning platform for all healthcare practitioners within this institution.
Despite the inevitability of error in humans, this institution believes the most medical errors that result in adverse health care events are secondary to negligence and can be prevented through best practices, such as medical reporting and the Critical Incident Reflective Exercise. Medical errors may harm or not harm patients but they must be reported to ensure that the culture of safety prevails and the healthcare working conditions are continuously evaluated (World Health Organization, 2016). This policy will act as a preventive measure for future incidents that may result from common and less-harmful issues in the healthcare system, especially near misses. The medical error reporting system will integrate errors that occur but do not result in patient harm, errors that harm patients, and mitigated errors that could have caused patient harm but were effectively eliminated. The establishment of a medical reporting and review system will promote a culture of safety through timely reporting and analysis of errors and near-miss calls for the identification of the root causes and development of preventative measures for the elimination of future errors.
The main objectives of this policy is to ensure immediate and long-term patient safety, support individual healthcare staff who are involved in medical errors and mitigation of future errors, providing a support framework for healthcare managers to deal with staff involved in medical errors, grading of errors for just and consistent treatment of involved staff, and creation of a learning platform through thorough and careful investigation into medical errors and interpretation for future elimination. Nurses, physicians, pharmacists, and other health practitioners will be responsible for the completion of medication error notification in the event of the discovery of a medical error, and a medication error sheet in the occurrence of an error.
The Management of Medical Errors Policy seeks to empower the leaders to emphasize patient safety through frontline actions that identify and resolve errors, in addition to systematic reflection on healthcare incidents and learning from the performance. Medical errors must be identified and overcome for improvement of the healthcare system, rather than a biased focus on blame, shame, and punishment that is likely to have adverse impacts on the practitioners and hinder error reporting. Omission errors occur when practitioners fail to take action, such as failure to strap a patient into a wheelchair, whereas commission errors occur as a result of wrong actions, such as wrongful administration of medication to a patient with an identified allergy (Rodziewicz & Hipskind, 2019). Medication errors are the most common in health care due to the presence of comprehensive management processes that include ordering, transcription, preparation, delivery, and administration of different drugs to patients (World Health Organization, 2016). All staff engaged in the prescription, dispensation, and administration of medical drugs will be required to demonstrate understanding and compliance with the relevant professional guidance, policies, and procedures. Each staff has the responsibility of acquiring and demonstrating relevant knowledge, skills, confidentiality, and competencies relating to medical procedures. None of the staff should engage in a medical procedure if they feel incompetent, except for professional students under direct supervision.
Any staff who report medical errors promptly will be exempted from any disciplinary action unless there is a detection of malice or crime, gross carelessness, or the adverse event is similar to other incidents that this organization has provided prior training and guidance. The correct medication, dosage, route, and rate must always be adhered to. Patients’ clinical conditions and parameters must be evaluated before prescription and all prescriptions signed by the prescriber (Rodziewicz & Hipskind, 2019). Medication must be clearly and correctly labeled and an information system used in sharing patient data for effective follow-up and implementation of care processes. Errors will be recognized and reviewed after self-reporting by the staff members, patient/representative complaints, reports by colleagues, routine audits, impromptu or spot audits by managers, and/or patient/representative reporting. Any healthcare practitioner responsible for a medical error must complete a medical error sheet that entails: name of the individual, patient’s name and number, date/time of the incident, type and reason of the error, incident description, description of the impact of the error on the patient, and the name of the manager/leader/supervisor that was notified. The Quality Assurance Department and nurse manager take over for evaluation of the incident, reflection, mentoring, and disciplinary action.