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Systems and resources

Systems

Errors have a tendency to compound themselves, so it is worth taking the time to ensure that essential tasks are carried out carefully. Many complaints arise from simple mistakes that could have been easily avoided.

The most common systems failures are:

  • failure to pass on important information
  • failure to arrange appointments, investigations or referrals with the appropriate degree of urgency
  • failure to review the results of investigations
  • failure to arrange follow-up and monitoring
  • mislabelling, misfiling and failure to check labels.
It is worth taking the time to ensure that essential tasks are carried out carefully

Box 13: Minimising administrative risks

Transfers of care

This includes shift handovers, transfers to other wards and departments, transfers between hospitals and discharge home. In all these scenarios it is crucial that those taking over the patient’s care be equipped with up-to-date key information. At a minimum, it should include diagnosis, treatment plans, medications, outstanding tests and test results.

Tests and investigations

When arranging urgent tests and investigations, let the lab know who they should contact with the results, especially if you are likely to be off-duty by the time they are available (and be sure to let the incoming shift know). Make a note in the patient’s record whenever tests and investigations are arranged, and record the results once they are available. Any abnormal results should be acted upon, not just filed in the notes.

Patient identification

Make a habit of checking a patient’s identity – either by asking the patient or by checking the wristband – before administering any treatment. Don’t rely on names on bedheads or on the charts at the foot of the bed as patient may have got – or been put – into the wrong bed. For handover, use a combination of identifying information (eg, name, age, DOB, diagnosis, bed number) to avoid confusion over patients with the same or similar-sounding names. Do not rely solely on bed or bay numbers to refer to patients as these may change.

Record keeping

Record any crucial information as soon after the event as possible.

Follow appropriate systems

Every hospital should have policies and procedures in place for checking medications, identifying the site of an operation, counting swabs and instruments, and so on. Even so, there are numerous incidents, complaints and negligence claims to show that these checks are far from foolproof; if you place too much trust in them, you may easily become complacent and assume that they have been carried out competently.

  • Before carrying out a procedure, always check the patient’s identity and look at the case notes and relevant images to establish the nature and site of the procedure, even if someone else has already prepared or marked the site.
  • Familiarise yourself with your hospital’s policy on ordering and administering blood products.
  • Make sure that any specimens and accompanying forms or reports are accurately and fully labelled.
  • See that all hazardous substances and waste are labelled with appropriate warnings.
  • Be conscious of health and safety issues, eg, disposal of sharps, etc.
Every hospital should have policies and procedures in place for checking medications, identifying the site of an operation, and counting swabs and instruments
No-one is perfect, so you will occasionally overlook, forget, or not be aware of crucial information that has an important bearing on a patient’s wellbeing. Patients therefore have an important role to play in the information system. If they are kept well informed and are encouraged to voice their concerns, they can act as a vital failsafe in the information system. Patients usually know what they’re in hospital for; they know their medical history, they’re usually familiar with their medication, they have their own welfare high on their agendas, and they rarely mistake themselves for another patient. It therefore makes good sense to stop and listen to them if they express concern about an intended procedure or treatment.

Adverse incident reporting system

What do you do if something goes wrong, or you have a close call? Do you think about reporting the incident? Many hospitals have an adverse incident reporting system to help them identify safety hotspots and to learn from experience. If your hospital has such a system, you should report any adverse incidents or “near misses” as soon as possible after the event.

Resources

If you have concerns about the effects of under-resourcing on patient safety, you should formally notify the hospital management, explaining why you are concerned and outlining the possible consequences of continued under-resourcing. In some respects this is a “back-covering” exercise. If you are involved in litigation following an adverse incident due to resourcing problems, the fact that you had alerted managers to the problem may assist your defence.

On a less cynical note, it is important that managers who are trying to balance limited budgets know where the risks to patient safety lie so that they may direct the hospital’s finite resources where they are most needed.

Staffing levels

After only one night of missed sleep your cognitive performance may decrease by 25% and, after a second night of missed sleep, you will probably be functioning at only 40% of baseline

If you work in an under-staffed hospital, you probably work excessively long hours. You will know from direct experience the effects this can have on your ability to function effectively, but you may still be interested to know that after only one night of missed sleep your cognitive performance may decrease by 25% and, after a second night of missed sleep, you will probably be functioning at only 40% of baseline.

If you accumulate a sleep debt (getting two to three hours’ less sleep than optimal in 24 hours) over five to ten days, you will not only find it difficult to function cognitively, but your response times will be lowered and your mood altered. You will also probably find your morale and sense of initiative adversely affected.11

Obviously, all of the above have implications for the safety and wellbeing of your patients. So is there anything you can do to miminise the risks? Yes, there is. Although you cannot eliminate all the risks associated with fatigue, there are things you can do to improve your performance or to guard against some of the worst effects of fatigue.

  • You should guard against a natural tendency to be short-tempered, irritable or rude when you are over-tired. This case report is a good illustration of what can happen if you give in to the temptation to just snap at a colleague rather than consider what they are trying to tell you.
  • Try not to rely on caffeine and sugar to see you through. Both of these substances will give you a short-term boost but then bring you crashing down a couple of hours later. They have the additional disadvantage of making it difficult to sleep when you do finally get off duty. Although your over-tired body will probably start nagging at you to feed it something sweet, you will do better to give it a piece of fruit or a homemade sandwich rather than something from a vending machine.
  • When it comes to meals, frequent snacks will serve you better during a long shift than large dinners, which require a lot of digestion and can make you sleepy. Try not to go too long without eating, and try to stick to complex carbohydrates and proteins. Drink plenty of water.
  • There are some indications from research that taking a prophylactic nap before you go on duty can effectively reduce feelings of fatigue. Maintenance naps during your shift may also be useful, but there is a risk of “sleep inertia” after being woken. Sleep inertia is the term used for that awful feeling of complete disorientation when you’re awoken from a deep sleep. It may last for up to 30 minutes, so this is not ideal if you are working on call where you are likely to have to deal with emergency situations.
  • Off duty, it’s important that you catch up with your sleep so that you don’t end up chronically sleep-deprived. This may be difficult if you’re trying to sleep during the daytime, when the quality of your sleep may be reduced by light, noise and temperature. You should do your best to replicate night-time conditions by using blackout curtains or an eyemask, earplugs and a fan or airconditioner to keep the room reasonably cool. Here are some techniques for promoting sleep:
    • “go for a short walk, relax with a book, listen to music and/or take a hot bath before going to bed
    • avoid vigorous exercise before sleep as it is stimulating and raises the body temperature
    • avoid caffeine, ‘energy’ drinks and other stimulants a few hours before bedtime as they can stop you going to sleep
    • don’t go to bed feeling hungry: have a light meal or snack before sleeping but avoid fatty, spicy and/or heavy meals as these are more difficult to digest and can disturb sleep
    • avoid alcohol as it lowers the quality of sleep.”12