Analysis of Medical Errors using HFACS
Added on 2021-04-19
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Running Header; Case Study ReviewStudent nameTask Human Patient SafetyVideo review on medical errorUniversity
H u m a n P a t i e n t S a f e t yCase study review on Human Patient SafetyIntroduction The use of HFACS (Human Factors Analysis Classification system) framework in health sector is a critical tool in assessment of root cause analysis of human practice gaps. The tool entails causal categories which exonerate four levels of error causation and various nanocodes aligned to it. In assessing medical practice, these tools will be utilised in reviewingthe video on Learning From Error. The framework herein details how various aspects of the tier interplay and impact on human factors and its effects on patient safety, (Diller et al.2014). In health care practice the prevalence of medical errors has recorded high numbers with1 in every 10 patients being taken in for medication for suffering from forms of medical malpractice. In some cases it has led to death of patients and major disability cases in health care delivery, (Donaldson et al. 2000).In this analysis we shall focus on a case study in which a patient destined for cancer therapy medication was administered wrong injection medication which could lead to serious medical case for the patient.Factors that contributed to errorProfessional misconduct Factors that may have led to the pharmacist breaking the protocol are many and varied. This could have been attributed to heavy work schedule and tough working conditions which don’t offer an opportunity for the questioning of the doctor in charge. The doctor was administering chemotherapy medication for patient Jean Hughes. The doctor based on his specialization should not have allowed administering the medication since he was an expertise in that field. However despite this the nurse allowed him to operate in the ward while the pharmacist gave him the medication irrespective of questioning its usage.Lack of basic standard operating proceduresIn most health care settings, there have been set and laid down procedures which offer strict guidance’s on the use of chemotherapy drugs. Such procedures have incorporated avenues such as prohibition of mixed storage of drugs with other medications and its therapeutic nature clearly outlined. These rules and regulations are referred to as standard operating procedures which allow treatments to be given in a specialised rooms or bays. The illustration of the case study showed that the basic guidelines were not followed in offering medication process to patient Jane. The mix up of the two medications led to breach of the setprotocol and it could to severe medical complications. 2
H u m a n P a t i e n t S a f e t yActs that led to the medical errorSkill based errorThe case study illustrated how Dr. Campbell mistakenly administered wrong medication on the patient. The medical doctor finds himself in a difficult position having an open spinal syringe for and on the other hand has lethal drug which he later injected to the patient completing the cycle of the medical error act. If critical care process had been taken, these acts could have been prevented.Decision based errorThe drug which the patient was injected could have been avoided if a protocol had beenadhered to. The injection of the drug was lethal to the patient and could have significant harm. Failure for the doctor and the nurse to confirm accurately the medication process led topoor decision making process. Further Dr. Campbell being not qualified to perform such kind of care to the patient, should not have been allowed to perform chemotherapy session to the patient. Despite the nurse knowledge on the doctor, she blatantly allowed the doctor to perform the care leading to acts of medical error.Perceptual errorThe actions of care portrayed in the case study shows how generalized care and unsafe systems can lead to medical errors. The error made based on the prescription of patient Jane Hughes and mix up of drugs led to the medical error commission. The full prescription is signed with ignorance of any standard operating procedures to be followed by the medical practitioner in administering the drug to the patient.Exceptional errorExceptional errors have been performed in this medical performance in the manner that the set procedures have been misunderstood. This can be traced to poor organizational structure, lack of clear communication poor coordination and professional negligence, could have led to lack of adherence, (Diller et al. 2014).The medical practitioner handling the patient blatantly violated the standard procedures and safety measures with regard to the pharmacist allowing both drugs to be taken without prior justification on the usage. Precondition for the Unsafe actsSkilled based error and Decision based error3
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