Matthew Grissinger: No relevant disclosure to display
On March 25, 2022, most of the healthcare community were shocked and dismayed after learning that a nurse had been convicted of criminally negligent homicide and gross neglect of an impaired adult. This case involved a combination of both active failures, including human errors and unsafe behavioral choices as well as latent failures within the organization. Regrettably, healthcare organizations tend to turn a blind eye to both risky systems and risky choices, believing patients are safe if bad outcomes—meaning harmful or fatal errors—do not happen to them. However, this type of error could happen anywhere given the current system vulnerabilities frequently found in hospitals. This program will give an overview of the breakdowns in the medication-use process in this case as well as list examples of both active and latent failures. A discussion of organization’s responses to human error, at-risk behaviors and to those who suffer emotionally when the care they provide leads to patient harm (often referred to as second victims). Proactive ways to identify risk, including the use of error reporting programs and improving staff engagement to address unsafe practices before an error occurs. The program will conclude with a discussion of effective risk reduction strategies to prevent harm to patients.
Differentiate between human errors and at-risk behaviors.
List factors that can degrade human performance and lead to human error.
Describe methods of proactively identifying risk in your organization.
Explain the differences between low and high leverage strategies.