Section 2 Patient Safety

*Nursing - New Perspectives*

[51] Corvetto MA, Fuentes C, Araneda A, Achurra P, Miranda P, Viviani P, et al. Validation of the imperial college surgical assessment device for spinal anesthesia. BMC Anesthesiology. 2017;**17**(1):131. DOI: 2010;**81**(4):446-452. DOI: 10.1016/j.

[58] Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in healthcare. BMJ Simulation and Technology Enhanced Learning. 2018. DOI: 10.1136/bmjstel-2018-000370.

resuscitation.2009.11.027

[Published Online]

10.1155/2016/4237523

[59] Green M, Tariq R, Green P. Improving patient safety through simulation training in anesthesiology: Where are we? Anesthesiology Research and Practice. 2016;**2016**:4237523. DOI:

[60] Cook DA, Aj L, Garside S. Method

Education. 2011;**45**(3):227-238. DOI: 10.1111/j.1365-2923.2010.03890

[62] Zendejas B, Brydges R, Wang AT, Cook DA. Patient outcomes in

simulation-based medical education: A systematic review. Journal of General Internal Medicine. 2013;**28**(8):1078-1089.

DOI: 10.1007/s11606-012-2264-5

and reporting quality in health professions education research: A systematic review. Medical

[61] Gordon M, Darbyshire D, Baker P. Non-technical skills training to enhance patient safety: A systematic

review. Medical Education. 2012;**46**(11):1042-1054. DOI: 10.1111/j.1365-2923.2012.04343

10.1186/s12871-017-0422-3

[52] Aggarwal R, Dosis A, Bello F, Darzi A. Motion tracking systems for assessment of surgical skill. Surgical Endoscopy. 2007;**21**(2):339. DOI: 10.1007/s00464-005-0561-3

[53] Corvetto MA, Altermatt FR. Tracking motion devices as assessment tools in anesthesia procedures: Have we been using them well? CJEM. 2017;**19**(5):412-413. DOI: 10.1017/

[54] Clinkard D, Holden M, Ungi T, Messenger D, Davison C, Fichtinger G, et al. The development and validation

evaluate competency in central line catheterization. Academic Emergency Medicine. 2015;**22**(2):212-218. DOI:

Rutherford J, Vincent L, Young D, Vincent C. Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: A systematic review. BMJ Quality and Safety. 2019;**28**(8):672-686. DOI: 10.1136/bmjqs-2018-008565

[56] Boet S, Etherington N, Larrigan S, Yin L, Khan H, Sullivan K, et al. Measuring the teamwork performance

systematic review of assessment tools and their measurement properties. BMJ Quality and Safety. 2019;**28**:327-337. DOI: 10.1136/bmjqs-2018-008260

of teams in crisis situations: A

[57] Cooper S, Cant R, Porter J, Sellick K, Somers G, Kinsman L, et al. Rating medical emergency teamwork performance: Development of the TEAM emergency assessment measure (TEAM). Resuscitation.

of hand motion analysis to

[55] Higham H, Greig PR,

10.1111/acem.12590

cem.2017.337

**32**

**35**

**Chapter 3**

**Abstract**

**1. Introduction**

and error recovery strategies.

**2. Magnitude of medical errors**

*Theresa A. Gaffney*

Keeping Patients Safe: The Critical

Two decades after the Institute of Medicine Report, To Err is Human: Building a Safer Health System illuminated the high number of preventable deaths and adverse events associated with health care, medical errors remain a top global concern. To date, resources have been focused on preventing medical errors; however, the importance of error recovery must not be overlooked. Medical errors cannot be fully eliminated from our health care system, yet many errors can be recovered thus preventing patient harm. This chapter will (1) define and describe the error recovery process, (2) discuss the role of health care providers in error recovery, (3) explore strategies that enhance and prohibit error recovery, and (4) analyze characteristics that influence error recovery. Given the importance of patient safety within the health care industry, health care professionals and organizations must focus on both error prevention and error recovery as a key strategy in keeping patients safe.

**Keywords:** medical errors, error recovery, near miss, patient safety, expertise,

Four out of every 10 patients are harmed while receiving care; costing payers an average of \$8000 per admission [1, 2]. Errors related to diagnosis, medication errors, and unsafe surgical procedures are most frequently reported [1]. Over the past two decades, numerous resources and attention have been devoted to preventing medical errors and adverse events. Yet, in complex, high-risk systems, eliminating errors is unrealistic [3]. Safety practices must incorporate both error prevention

This chapter will focus on error recovery as a critical safety strategy. Topics discussed in this chapter include (1) the error recovery process, (2) the role of health care providers in error recovery, (3) strategies that enhance and prohibit error recovery, and (4) individual and organizational characteristics that influence error recovery.

Health care harm is a top safety concern globally. Medical errors occur when actions (intended or unintended) fail to meet their desired outcome, an action is not completed as intended, or the wrong action is taken to achieve an aim [4, 5]. In other words, errors result from unintended consequences as well as when health care providers make the wrong decision. The Institute of Medicine's (IOM) seminal

culture, leadership, workload, high reliability

Role of Medical Error Recovery

## **Chapter 3**

## Keeping Patients Safe: The Critical Role of Medical Error Recovery

*Theresa A. Gaffney*

## **Abstract**

Two decades after the Institute of Medicine Report, To Err is Human: Building a Safer Health System illuminated the high number of preventable deaths and adverse events associated with health care, medical errors remain a top global concern. To date, resources have been focused on preventing medical errors; however, the importance of error recovery must not be overlooked. Medical errors cannot be fully eliminated from our health care system, yet many errors can be recovered thus preventing patient harm. This chapter will (1) define and describe the error recovery process, (2) discuss the role of health care providers in error recovery, (3) explore strategies that enhance and prohibit error recovery, and (4) analyze characteristics that influence error recovery. Given the importance of patient safety within the health care industry, health care professionals and organizations must focus on both error prevention and error recovery as a key strategy in keeping patients safe.

**Keywords:** medical errors, error recovery, near miss, patient safety, expertise, culture, leadership, workload, high reliability

## **1. Introduction**

Four out of every 10 patients are harmed while receiving care; costing payers an average of \$8000 per admission [1, 2]. Errors related to diagnosis, medication errors, and unsafe surgical procedures are most frequently reported [1]. Over the past two decades, numerous resources and attention have been devoted to preventing medical errors and adverse events. Yet, in complex, high-risk systems, eliminating errors is unrealistic [3]. Safety practices must incorporate both error prevention and error recovery strategies.

This chapter will focus on error recovery as a critical safety strategy. Topics discussed in this chapter include (1) the error recovery process, (2) the role of health care providers in error recovery, (3) strategies that enhance and prohibit error recovery, and (4) individual and organizational characteristics that influence error recovery.

### **2. Magnitude of medical errors**

Health care harm is a top safety concern globally. Medical errors occur when actions (intended or unintended) fail to meet their desired outcome, an action is not completed as intended, or the wrong action is taken to achieve an aim [4, 5]. In other words, errors result from unintended consequences as well as when health care providers make the wrong decision. The Institute of Medicine's (IOM) seminal report *To Err is Human*, first alerted the health care community and the public to the widespread nature of deaths attributed to medical errors [6]. According to the IOM, 44,000 to 98,000 patient deaths were attributed to medical errors in the United States annually [4]. A decade later, Classen et al. estimated that the medical error rate among hospitalized Medicare beneficiaries was nearly four times that of the IOM estimate [7]. Over the past two decades, national efforts to reduce medical errors have led to some improvement. For example, hospital-acquired conditions (HACs) declined by nearly 1 million instances from 2014 to 2017 [8]. Despite these efforts, in 2019, the World Health Organization (WHO) reported that globally, four out of every 10 patients are harmed while receiving care and at least five patients die every minute as a result of medical errors [1]. Although the exact number of patient deaths attributed to medical errors remains debatable, preventable deaths and adverse events are a significant safety issue.

Research investigating the nature and impact of medical errors within the health care system began in earnest in the 1990s. Initially, human behavior, such as carelessness, poor motivation, and inattention, was blamed as the source of medical errors [6]. However, a shift away from the physiological and psychological limitations of humans and toward system error introduced new safety lessons from areas outside of the traditional health care arena [3, 6, 9]. Strategies adapted from safetycritical industries such as transportation, manufacturing, and aviation brought forward important gains in the fight to improve patient safety.

Aviation safety, for example, depends on managing errors, both through prevention and recovery [9]. In 1995, the US Secretary of Transportation challenged the aviation industry to meet the goal of zero accidents [10]. Interventions such as crew resource management training, checklists, and new technologies were introduced to address attitudes, behavior, and performance with the goal of improving aviation safety. Considerable efforts and resources were invested in the industry to limit opportunities for human error. However, human error is inevitable, particularly in complex, high-hazard organizations, and the goal of zero errors was unrealistic [3]. As a result, the aviation industry recognized the importance of error recovery and began training pilots to identify and remediate errors when they occurred [11].

Still, health care is focused on preventing medical errors, leaving behind important lessons in correcting errors to reduce adverse events. Health care historically equates errors with failure, and failure is unacceptable [12]. Thus, the notion of error management is not easily embraced. Error management involves understanding the nature and extent of errors, changing the conditions that create errors, identifying behaviors and actions that mitigate damage from errors, and training personnel in their use [9]. Error management incorporates two unique aspects [6]. The first aspect is prevention or limiting the incidence of errors. The second aspect is containing the damaging effects of errors, also referred to as error recovery. Error recovery is a highly valued strategy in safety programs outside of health care and is emerging as an important safety strategy in keeping patients safe [13].

## **3. Complexity**

Health care systems are highly complex organizations, consisting of numerous interconnected components including the patients and their condition, the procedure, the team's expertise, the equipment design and use, and the workload [4]. Communication and the urgency in which decisions are made add further complexity to the system. Finally, these complex systems operate in highly variable environments that are impacted by regulatory, fiscal and social considerations.

**37**

*Keeping Patients Safe: The Critical Role of Medical Error Recovery*

organizations on the journey toward high reliability.

ered before harm occurs, this is defined as a near miss.

adaptability of health care providers in recovering errors.

greater strides in improving patient safety.

**4. Error recovery model**

**5. Error recovery process**

errors [16, 20, 21].

High-reliability organizations (HROs) are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures [14]. HROs are not immune to errors and adverse events, instead, they are preoccupied with failure. Defining features of HROs include their heightened sense of vigilance and ability to anticipate and detect problems early in order to prevent adverse events. HROs have learned to make systems as tolerant as possible toward error [6]. Understanding error recovery can support health care

In safety-critical systems, error recovery is equally as important as error prevention, as it is often the last barrier of defense before a near miss becomes an adverse event [15]. Error recovery is highly valued in other industries outside of health care, yet it is just beginning to be recognized as an important safety strategy in health care [16]. Both error prevention and error recovery strategies are needed to make

The Eindhoven Model of Near Miss Reporting has been used to explore and define error recovery in safety-critical industries [17]. Errors stem from technical, organizational or human factors that set off a chain reaction that could result in adverse events. When dangerous situations develop, systems are designed with automatic safety mechanisms to prevent negative consequences. In the case of high-risk situations however, automatic safety mechanisms are not always enough to resolve errors. In these instances, human intuition, expertise, and flexibility are needed to intervene and recover the error before harm occurs. If the error is recov-

The Eindhoven model offers insight into error recovery processes in health care settings [15]. Henneman and Gawlinski adapted the Eindhoven model to create the Nursing Near-Miss model to better understand the mechanisms nurses use to recover errors at the point of care. In this model, bedside nurses are the final line of defense between a near miss and an adverse event. The researchers pointed out that surveillance is a key strategy nurses use to prevent developing incidents from becoming adverse events. A growing body of literature describes the ingenuity and

Error recovery is a three-step sequential process incorporating (1) identification, (2) interruption and (3) correction [17–19]. First, an error must be detected. Error identification or detection is the process of knowing that an error occurred and may be triggered by a mismatch in an expected outcome. This step is aimed at making errors quickly apparent, thereby enabling recovery. Factors such as knowing the patient, players, plan of care, and the environment aid in identifying medical

Interrupting an error is the second step in the error recovery process. In this step, participants attempt to understand how the error occurred, the level of importance, and potential countermeasures that may be necessary to return the situation to normal [20–23]. Health care providers interrupt errors using actions such as offering assistance, clarifying orders, and even verbally interrupting [16].

Perseverance is key to correcting errors, particularly when error identification

or interruption was not successful [16]. In this step, the focus is on deploying

*DOI: http://dx.doi.org/10.5772/intechopen.91412*

#### *Keeping Patients Safe: The Critical Role of Medical Error Recovery DOI: http://dx.doi.org/10.5772/intechopen.91412*

High-reliability organizations (HROs) are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures [14]. HROs are not immune to errors and adverse events, instead, they are preoccupied with failure. Defining features of HROs include their heightened sense of vigilance and ability to anticipate and detect problems early in order to prevent adverse events. HROs have learned to make systems as tolerant as possible toward error [6]. Understanding error recovery can support health care organizations on the journey toward high reliability.

In safety-critical systems, error recovery is equally as important as error prevention, as it is often the last barrier of defense before a near miss becomes an adverse event [15]. Error recovery is highly valued in other industries outside of health care, yet it is just beginning to be recognized as an important safety strategy in health care [16]. Both error prevention and error recovery strategies are needed to make greater strides in improving patient safety.

## **4. Error recovery model**

*Nursing - New Perspectives*

adverse events are a significant safety issue.

report *To Err is Human*, first alerted the health care community and the public to the widespread nature of deaths attributed to medical errors [6]. According to the IOM, 44,000 to 98,000 patient deaths were attributed to medical errors in the United States annually [4]. A decade later, Classen et al. estimated that the medical error rate among hospitalized Medicare beneficiaries was nearly four times that of the IOM estimate [7]. Over the past two decades, national efforts to reduce medical errors have led to some improvement. For example, hospital-acquired conditions (HACs) declined by nearly 1 million instances from 2014 to 2017 [8]. Despite these efforts, in 2019, the World Health Organization (WHO) reported that globally, four out of every 10 patients are harmed while receiving care and at least five patients die every minute as a result of medical errors [1]. Although the exact number of patient deaths attributed to medical errors remains debatable, preventable deaths and

Research investigating the nature and impact of medical errors within the health care system began in earnest in the 1990s. Initially, human behavior, such as carelessness, poor motivation, and inattention, was blamed as the source of medical errors [6]. However, a shift away from the physiological and psychological limitations of humans and toward system error introduced new safety lessons from areas outside of the traditional health care arena [3, 6, 9]. Strategies adapted from safetycritical industries such as transportation, manufacturing, and aviation brought

Aviation safety, for example, depends on managing errors, both through prevention and recovery [9]. In 1995, the US Secretary of Transportation challenged the aviation industry to meet the goal of zero accidents [10]. Interventions such as crew resource management training, checklists, and new technologies were introduced to address attitudes, behavior, and performance with the goal of improving aviation safety. Considerable efforts and resources were invested in the industry to limit opportunities for human error. However, human error is inevitable, particularly in complex, high-hazard organizations, and the goal of zero errors was unrealistic [3]. As a result, the aviation industry recognized the importance of error recovery and began training pilots to identify and remediate errors when they

Still, health care is focused on preventing medical errors, leaving behind important lessons in correcting errors to reduce adverse events. Health care historically equates errors with failure, and failure is unacceptable [12]. Thus, the notion of error management is not easily embraced. Error management involves understanding the nature and extent of errors, changing the conditions that create errors, identifying behaviors and actions that mitigate damage from errors, and training personnel in their use [9]. Error management incorporates two unique aspects [6]. The first aspect is prevention or limiting the incidence of errors. The second aspect is containing the damaging effects of errors, also referred to as error recovery. Error recovery is a highly valued strategy in safety programs outside of health care and is

Health care systems are highly complex organizations, consisting of numerous interconnected components including the patients and their condition, the procedure, the team's expertise, the equipment design and use, and the workload [4]. Communication and the urgency in which decisions are made add further complexity to the system. Finally, these complex systems operate in highly variable environ-

emerging as an important safety strategy in keeping patients safe [13].

ments that are impacted by regulatory, fiscal and social considerations.

forward important gains in the fight to improve patient safety.

**36**

occurred [11].

**3. Complexity**

The Eindhoven Model of Near Miss Reporting has been used to explore and define error recovery in safety-critical industries [17]. Errors stem from technical, organizational or human factors that set off a chain reaction that could result in adverse events. When dangerous situations develop, systems are designed with automatic safety mechanisms to prevent negative consequences. In the case of high-risk situations however, automatic safety mechanisms are not always enough to resolve errors. In these instances, human intuition, expertise, and flexibility are needed to intervene and recover the error before harm occurs. If the error is recovered before harm occurs, this is defined as a near miss.

The Eindhoven model offers insight into error recovery processes in health care settings [15]. Henneman and Gawlinski adapted the Eindhoven model to create the Nursing Near-Miss model to better understand the mechanisms nurses use to recover errors at the point of care. In this model, bedside nurses are the final line of defense between a near miss and an adverse event. The researchers pointed out that surveillance is a key strategy nurses use to prevent developing incidents from becoming adverse events. A growing body of literature describes the ingenuity and adaptability of health care providers in recovering errors.

## **5. Error recovery process**

Error recovery is a three-step sequential process incorporating (1) identification, (2) interruption and (3) correction [17–19]. First, an error must be detected. Error identification or detection is the process of knowing that an error occurred and may be triggered by a mismatch in an expected outcome. This step is aimed at making errors quickly apparent, thereby enabling recovery. Factors such as knowing the patient, players, plan of care, and the environment aid in identifying medical errors [16, 20, 21].

Interrupting an error is the second step in the error recovery process. In this step, participants attempt to understand how the error occurred, the level of importance, and potential countermeasures that may be necessary to return the situation to normal [20–23]. Health care providers interrupt errors using actions such as offering assistance, clarifying orders, and even verbally interrupting [16].

Perseverance is key to correcting errors, particularly when error identification or interruption was not successful [16]. In this step, the focus is on deploying

countermeasures to avert the error and reducing patient harm [20–23]. Being physically present, reviewing or confirming the plan of care, and involving other experts or leaders are successful strategies in correcting errors [16]. The system returns to its' safe state and patient harm is averted when errors are successfully recovered [19]. If errors are not successfully recovered, adverse events and potentially catastrophic consequences may occur.

Health care providers rely on flexibility, ingenuity, surveillance, and clinical judgment in recovering errors [16]. Henneman et al. first recognized the importance of surveillance in the error recovery process [15, 20, 21, 24]. Surveillance involves the continuous acquisition, analysis, and synthesis of information from both an individual and organizational perspective. Surveilling the patient and the environment enables providers to recognize developing complications and intervene appropriately. In contrast, when surveillance is lacking dangerous events may develop. Clinical judgment integrates knowledge, skills, expertise, and reasoning to recognize and address potentially dangerous situations [16]. Finally, providers use creativity and flexibility when devising and choosing appropriate strategies to interrupt and correct errors.

Researchers have attempted to quantify the number of errors recovered by health care providers. An integrated review of the literature noted that the magnitude of error recovery among nurses varies from as much as 18 times per 1000 patient days among medical-surgical nurses to as many as two errors per shift among critical care nurses [16]. Perioperative nurses have been known to recover as many as 11 errors per surgical case [22]. Nurses commonly recover errors related to medication errors, mismanagement of aversive systems, mismanagement of coexisting health issues, and improper use of precaution techniques in invasive monitoring [25]. Nurses accept that errors occur and see error recovery as an ongoing part of their job [15]. They regularly identify, interrupt, and correct errors, yet this information is rarely collected and analyzed. Thus, the important role that nurses contribute to patient safety is often invisible [16].

In addition to nurses, others play key roles in error recovery. A growing body of literature has explored strategies pharmacists employ to recover errors [23, 26]. Emergency department pharmacists were found to recover, on average, 7.8 medication errors per 100 patients [26]. A study of error recovery in community pharmacies found that pharmacists recovered numerous e-prescribing errors daily [23]. Most errors were caught at the identification stage of the error recovery process by pharmacists and technicians using strategies such as double checks and highlighting information on the printed e-prescription. Consulting with other pharmacy team members, reviewing the patient's history, and consulting with patients were strategies used to interrupt medication errors. Finally, pharmacists and technicians contacted prescribers to correct medication errors.

Patients and families also contribute to identifying and interrupting medical errors. A study of families of hospitalized children attempted to quantify the number of errors recovered by families. Benjamin et al. reported that 8% more medical errors were identified and interrupted when families were actively engaged with the health care team during family-centered rounds [27]. Families questioned medication changes, scheduling issues, and adverse drug reactions. The literature supports the notion that patients and families are increasingly involved in early error detection [28]. An analysis of near misses in the National Health Service found many instances of family members reminding staff about lapsed arrangements, pointing out overlooked care plans, and insisting on tests. The literature indicates that patients frequently identify communication and coordination related problems that may lead to adverse events [29]. Key strategies enabling them to prevent adverse events were knowing the patient and plan of care. Patients and families should be encouraged to actively engage in the care process and speak up when concerns arise [28].

**39**

*Keeping Patients Safe: The Critical Role of Medical Error Recovery*

strategies enabling health care providers to correct errors.

**6. Characteristics influencing error recovery**

recover medical errors than non-expert nurses [31].

help or hinder error recovery.

**6.1 Individual characteristics**

performance.

While there is no standardized approach to capturing the magnitude of medical errors, front-line providers, as well as patients and families, play critical roles in recovering errors. Patients and families contribute to ongoing surveillance through active engagement in the care process. Effective communication between health care team members, patients and families aids in identifying and interrupting medical errors. Flexibility, creativity, clinical judgment, and surveillance are key

Health care organizations are striving toward resilience during turbulent times in which they continue to struggle with access, cost and quality issues. Providers are challenged to make intricate decisions in dynamic, fast-paced, complex environments under tight time constraints. Errors are likely to occur under such conditions. Individual characteristics and organizational structures and processes can either

Individual characteristics that influence error recovery include expertise and workload [16]. Experts, like non-experts, are not immune to errors. However, what is unique about experts, is that they can recover errors more quickly than non-experts [12]. Experts unconsciously organize knowledge into manageable chunks that allow them to access and use critical information when necessary [12, 16, 30–32]. Experts rely on past experiences to help them identify cues and recognize patterns. They are better able to synthesize explicit and tacit knowledge in meaningful ways as compared to non-experts. Experts separate critical and relevant information from irrelevant information. In the end, experts develop what is known as deep smarts, a special form of wisdom that incorporates social, emotional, formal, and experiential knowledge [32]. As clinicians develop deep smarts, they exhibit greater confidence, perform more efficiently, and achieve higher levels of

In the health care arena, experts use a multi-dimensional approach to integrate clinical judgment with knowledge of the patient, environment, and plan of care that allows them to more readily recover errors [16, 20, 21, 31]. A laboratory study of attending critical care physicians, residents, and medical students exploring the relationship between expertise and error recovery found that experts (physicians) recovered more (75%) errors than residents (61%) [33]. A study exploring the ability of dialysis nurses to recover errors determined that expert nurses detected more errors than non-expert nurses [34]. A study exploring error recovery among medical-surgical nurses found that expert nurses were four times more likely to

Another hallmark of expertise is knowing when to deviate from standard protocols and employ shortcuts [35]. The ability to gauge tolerable risk in clinical situations is acquired over time and can only reside within experts. A study of trauma physicians and residents found that expert physicians made fewer errors when deviating from standard protocols than first- and second-year residents [31]. When deviations from standards or countermeasures are required to prevent

Workload is also associated with error recovery. When workload increases, nurses' ability to recover errors decreases [13, 31]. The notion of workload incorporates the demand placed on one's cognitive function, physical energy and the

adverse events the role of expertise should not be underestimated.

*DOI: http://dx.doi.org/10.5772/intechopen.91412*

While there is no standardized approach to capturing the magnitude of medical errors, front-line providers, as well as patients and families, play critical roles in recovering errors. Patients and families contribute to ongoing surveillance through active engagement in the care process. Effective communication between health care team members, patients and families aids in identifying and interrupting medical errors. Flexibility, creativity, clinical judgment, and surveillance are key strategies enabling health care providers to correct errors.

## **6. Characteristics influencing error recovery**

Health care organizations are striving toward resilience during turbulent times in which they continue to struggle with access, cost and quality issues. Providers are challenged to make intricate decisions in dynamic, fast-paced, complex environments under tight time constraints. Errors are likely to occur under such conditions. Individual characteristics and organizational structures and processes can either help or hinder error recovery.

## **6.1 Individual characteristics**

*Nursing - New Perspectives*

countermeasures to avert the error and reducing patient harm [20–23]. Being physically present, reviewing or confirming the plan of care, and involving other experts or leaders are successful strategies in correcting errors [16]. The system returns to its' safe state and patient harm is averted when errors are successfully recovered [19]. If errors are not successfully recovered, adverse events and

Health care providers rely on flexibility, ingenuity, surveillance, and clinical judgment in recovering errors [16]. Henneman et al. first recognized the importance of surveillance in the error recovery process [15, 20, 21, 24]. Surveillance involves the continuous acquisition, analysis, and synthesis of information from both an individual and organizational perspective. Surveilling the patient and the environment enables providers to recognize developing complications and intervene appropriately. In contrast, when surveillance is lacking dangerous events may develop. Clinical judgment integrates knowledge, skills, expertise, and reasoning to recognize and address potentially dangerous situations [16]. Finally, providers use creativity and flexibility when devising and choosing appropriate strategies to interrupt and correct errors. Researchers have attempted to quantify the number of errors recovered by health care providers. An integrated review of the literature noted that the magnitude of error recovery among nurses varies from as much as 18 times per 1000 patient days among medical-surgical nurses to as many as two errors per shift among critical care nurses [16]. Perioperative nurses have been known to recover as many as 11 errors per surgical case [22]. Nurses commonly recover errors related to medication errors, mismanagement of aversive systems, mismanagement of coexisting health issues, and improper use of precaution techniques in invasive monitoring [25]. Nurses accept that errors occur and see error recovery as an ongoing part of their job [15]. They regularly identify, interrupt, and correct errors, yet this information is rarely collected and analyzed. Thus, the important role that

In addition to nurses, others play key roles in error recovery. A growing body of literature has explored strategies pharmacists employ to recover errors [23, 26]. Emergency department pharmacists were found to recover, on average, 7.8 medication errors per 100 patients [26]. A study of error recovery in community pharmacies found that pharmacists recovered numerous e-prescribing errors daily [23]. Most errors were caught at the identification stage of the error recovery process by pharmacists and technicians using strategies such as double checks and highlighting information on the printed e-prescription. Consulting with other pharmacy team members, reviewing the patient's history, and consulting with patients were strategies used to interrupt medication errors. Finally, pharmacists and technicians

Patients and families also contribute to identifying and interrupting medical errors. A study of families of hospitalized children attempted to quantify the number of errors recovered by families. Benjamin et al. reported that 8% more medical errors were identified and interrupted when families were actively engaged with the health care team during family-centered rounds [27]. Families questioned medication changes, scheduling issues, and adverse drug reactions. The literature supports the notion that patients and families are increasingly involved in early error detection [28]. An analysis of near misses in the National Health Service found many instances of family members reminding staff about lapsed arrangements, pointing out overlooked care plans, and insisting on tests. The literature indicates that patients frequently identify communication and coordination related problems that may lead to adverse events [29]. Key strategies enabling them to prevent adverse events were knowing the patient and plan of care. Patients and families should be encouraged to

actively engage in the care process and speak up when concerns arise [28].

potentially catastrophic consequences may occur.

nurses contribute to patient safety is often invisible [16].

contacted prescribers to correct medication errors.

**38**

Individual characteristics that influence error recovery include expertise and workload [16]. Experts, like non-experts, are not immune to errors. However, what is unique about experts, is that they can recover errors more quickly than non-experts [12]. Experts unconsciously organize knowledge into manageable chunks that allow them to access and use critical information when necessary [12, 16, 30–32]. Experts rely on past experiences to help them identify cues and recognize patterns. They are better able to synthesize explicit and tacit knowledge in meaningful ways as compared to non-experts. Experts separate critical and relevant information from irrelevant information. In the end, experts develop what is known as deep smarts, a special form of wisdom that incorporates social, emotional, formal, and experiential knowledge [32]. As clinicians develop deep smarts, they exhibit greater confidence, perform more efficiently, and achieve higher levels of performance.

In the health care arena, experts use a multi-dimensional approach to integrate clinical judgment with knowledge of the patient, environment, and plan of care that allows them to more readily recover errors [16, 20, 21, 31]. A laboratory study of attending critical care physicians, residents, and medical students exploring the relationship between expertise and error recovery found that experts (physicians) recovered more (75%) errors than residents (61%) [33]. A study exploring the ability of dialysis nurses to recover errors determined that expert nurses detected more errors than non-expert nurses [34]. A study exploring error recovery among medical-surgical nurses found that expert nurses were four times more likely to recover medical errors than non-expert nurses [31].

Another hallmark of expertise is knowing when to deviate from standard protocols and employ shortcuts [35]. The ability to gauge tolerable risk in clinical situations is acquired over time and can only reside within experts. A study of trauma physicians and residents found that expert physicians made fewer errors when deviating from standard protocols than first- and second-year residents [31]. When deviations from standards or countermeasures are required to prevent adverse events the role of expertise should not be underestimated.

Workload is also associated with error recovery. When workload increases, nurses' ability to recover errors decreases [13, 31]. The notion of workload incorporates the demand placed on one's cognitive function, physical energy and the

work pace itself [36]. Acute care settings are fast-paced, complex environments in which health care providers are constantly combining complex thinking processes with psychomotor and affective skills to deliver appropriate care and interventions [37]. Nurses, in particular, spend a great deal of time providing direct patient care and communicating with patients, families, and team members [38]. Patient care involves nursing process activities such as assessing patients' clinical conditions, judging the need for nursing care intervention, implementing nursing care measures, and evaluating the effects of therapy. Communication involves consulting with team members, delegating to others, and patient education. Nurses are forced to cognitively shifting between patients based on their condition, medications, therapies, and requests within tight timeframes. As stressors and demands build, the nurse's thought processes and attention are negatively affected. Error identification and interruption is a complex process that requires significant cognitive resources [39]. Consequently, when nurses are experiencing high cognitive loads, due to heavy patient assignments or workload, their cognitive defenses and capacity to recovery errors are diminished.

#### **6.2 Organizational characteristics**

In addition to individual characteristics that influence error recovery, there are organizational characteristics as well. These characteristics include a culture of safety and leadership.

A culture of safety is the most important organizational factor contributing to successful error recovery. Organizations with a strong culture of safety recover errors more readily [13, 16]. On average, there are 2.4 recovery opportunities per error [13]. When a recovery opportunity is missed, individuals and organizations have another opportunity to identify, interrupt and correct the error before harm occurs. Organizations that prioritize safety engage in practices and behaviors that enable ongoing surveillance and ultimately error recovery. Practices such as interdisciplinary bedside rounds, effective handoffs, reducing interruptions and facilitating open and ongoing communication enhance early identification and resolution of errors [20, 21, 27–29].

When organizations do not prioritize safety, errors are more likely to occur, and error recovery opportunities are missed. In this case, important safety checks are skipped, shortcomings in protocols and procedures are noted, and critical knowledge is not transferred between providers making it difficult for errors to be identified [13].

Supportive leadership is also an important organizational characteristic influencing error recovery. Studies noted that when all else fails, involving leadership in the final stage of error recovery is an effective countermeasure to prevent patient harm [20, 21, 31]. But the role of leadership goes well beyond stepping in as the voice of authority to recover errors. Financial constraints, time pressures, and performance constraints put additional strain on organizations and impact error recovery processes [36, 37]. Leadership must develop a portfolio of strategies aimed at managing errors that are coordinated between executives, middle management and frontline staff [40]. Middle managers can act as a buffer for front-line providers and negotiate for solutions to alleviate heavy workloads. Executives can ensure a culture of safety and prioritize safety over other domains when faced with competing pressures. Leadership decisions, at all levels, contribute to creating an environment that either facilitates or hinders error recovery at the point of care.

Organizations striving to consistently provide excellence in quality and safety for every patient, every time must make safety a priority. A key safety strategy in resilient organizations is early error detection and mitigation of medical errors [6].

**41**

**Conflict of interest**

*Keeping Patients Safe: The Critical Role of Medical Error Recovery*

particularly as health care becomes more complex.

detect problems early to prevent adverse events.

The author has no real or perceived conflicts of interest.

**7. Conclusion**

care must do the same.

**8. Case study**

This strategy must be embraced by the health care industry. Today, health care providers are making critical decisions in complex situations within tight time constraints which contribute to medical errors. When errors occur, expertise and workload are individual characteristics that enhance error recovery. Expertise must be retained and redeployed across the staff. Strategies to facilitate the transfer of expert knowledge or deep smarts to non-experts should be harnessed. Workload and staffing levels must facilitate error recovery. Thus, workload or care models that leverage expertise should be explored. Finally, systems and processes must be adapted to address the strengths and weaknesses of human cognitive functions,

This chapter described the error recovery process, highlighted the role of health care providers in error recovery, identified strategies that enhance and prohibit error, and explored individual and organizational characteristics that influence error recovery. Health care providers, patients, and families demonstrated ingenuity and adaptability when recovering errors. Flexibility, creativity, surveillance, and clinical judgment of health care providers are key strategies in identifying, interrupting and correcting medical errors. Characteristics that enhance error recovery include individual provider expertise and organizational culture of safety. A burdensome workload is an organizational characteristic that inhibits error recovery. The value of error recovery in keeping patients safe is clear, although undervalued in health care. Safety-critical industries recognize that errors cannot be fully eliminated and have embraced error recovery as a critical safety strategy. Health

Delivering chemotherapy to cancer patients is a high-risk activity with numerous opportunities for patient harm [41]. Although the incidence of medication errors in chemotherapy is low, the margin of error for administering toxic chemotherapeutic agents to cancer patients is very small. Memorial Sloan Kettering Cancer Center noticed that as the number of chemotherapy orders increased so too did the number of near-miss medication errors. To minimize medication errors, the hospital implemented the new role of a verification nurse (VN) to review all chemotherapy orders. If a discrepancy is noted in the chemotherapy order, VNs investigate the incident by referring to protocols, contacting the health care provider for clarification, referring to the patient's plan of care for updates or changes and maintaining open and ongoing communication with the team members. Evaluation of the new role noted a direct correlation between an increase in chemotherapy orders and patient volume with error recovery by VNs. While additional complexity added to an increased number of medical errors, the organization embraced the concept of error recovery. This is an example of how one hospital heightened their sense of vigilance and supported strategies to enable health care providers to anticipate and

*DOI: http://dx.doi.org/10.5772/intechopen.91412*

#### *Keeping Patients Safe: The Critical Role of Medical Error Recovery DOI: http://dx.doi.org/10.5772/intechopen.91412*

This strategy must be embraced by the health care industry. Today, health care providers are making critical decisions in complex situations within tight time constraints which contribute to medical errors. When errors occur, expertise and workload are individual characteristics that enhance error recovery. Expertise must be retained and redeployed across the staff. Strategies to facilitate the transfer of expert knowledge or deep smarts to non-experts should be harnessed. Workload and staffing levels must facilitate error recovery. Thus, workload or care models that leverage expertise should be explored. Finally, systems and processes must be adapted to address the strengths and weaknesses of human cognitive functions, particularly as health care becomes more complex.

## **7. Conclusion**

*Nursing - New Perspectives*

to recovery errors are diminished.

**6.2 Organizational characteristics**

resolution of errors [20, 21, 27–29].

safety and leadership.

identified [13].

work pace itself [36]. Acute care settings are fast-paced, complex environments in which health care providers are constantly combining complex thinking processes with psychomotor and affective skills to deliver appropriate care and interventions [37]. Nurses, in particular, spend a great deal of time providing direct patient care and communicating with patients, families, and team members [38]. Patient care involves nursing process activities such as assessing patients' clinical conditions, judging the need for nursing care intervention, implementing nursing care measures, and evaluating the effects of therapy. Communication involves consulting with team members, delegating to others, and patient education. Nurses are forced to cognitively shifting between patients based on their condition, medications, therapies, and requests within tight timeframes. As stressors and demands build, the nurse's thought processes and attention are negatively affected. Error identification and interruption is a complex process that requires significant cognitive resources [39]. Consequently, when nurses are experiencing high cognitive loads, due to heavy patient assignments or workload, their cognitive defenses and capacity

In addition to individual characteristics that influence error recovery, there are organizational characteristics as well. These characteristics include a culture of

A culture of safety is the most important organizational factor contributing to successful error recovery. Organizations with a strong culture of safety recover errors more readily [13, 16]. On average, there are 2.4 recovery opportunities per error [13]. When a recovery opportunity is missed, individuals and organizations have another opportunity to identify, interrupt and correct the error before harm occurs. Organizations that prioritize safety engage in practices and behaviors that enable ongoing surveillance and ultimately error recovery. Practices such as interdisciplinary bedside rounds, effective handoffs, reducing interruptions and facilitating open and ongoing communication enhance early identification and

When organizations do not prioritize safety, errors are more likely to occur, and error recovery opportunities are missed. In this case, important safety checks are skipped, shortcomings in protocols and procedures are noted, and critical knowledge is not transferred between providers making it difficult for errors to be

Supportive leadership is also an important organizational characteristic influencing error recovery. Studies noted that when all else fails, involving leadership in the final stage of error recovery is an effective countermeasure to prevent patient harm [20, 21, 31]. But the role of leadership goes well beyond stepping in as the voice of authority to recover errors. Financial constraints, time pressures, and performance constraints put additional strain on organizations and impact error recovery processes [36, 37]. Leadership must develop a portfolio of strategies aimed at managing errors that are coordinated between executives, middle management and frontline staff [40]. Middle managers can act as a buffer for front-line providers and negotiate for solutions to alleviate heavy workloads. Executives can ensure a culture of safety and prioritize safety over other domains when faced with competing pressures. Leadership decisions, at all levels, contribute to creating an environ-

ment that either facilitates or hinders error recovery at the point of care.

Organizations striving to consistently provide excellence in quality and safety for every patient, every time must make safety a priority. A key safety strategy in resilient organizations is early error detection and mitigation of medical errors [6].

**40**

This chapter described the error recovery process, highlighted the role of health care providers in error recovery, identified strategies that enhance and prohibit error, and explored individual and organizational characteristics that influence error recovery. Health care providers, patients, and families demonstrated ingenuity and adaptability when recovering errors. Flexibility, creativity, surveillance, and clinical judgment of health care providers are key strategies in identifying, interrupting and correcting medical errors. Characteristics that enhance error recovery include individual provider expertise and organizational culture of safety. A burdensome workload is an organizational characteristic that inhibits error recovery.

The value of error recovery in keeping patients safe is clear, although undervalued in health care. Safety-critical industries recognize that errors cannot be fully eliminated and have embraced error recovery as a critical safety strategy. Health care must do the same.

## **8. Case study**

Delivering chemotherapy to cancer patients is a high-risk activity with numerous opportunities for patient harm [41]. Although the incidence of medication errors in chemotherapy is low, the margin of error for administering toxic chemotherapeutic agents to cancer patients is very small. Memorial Sloan Kettering Cancer Center noticed that as the number of chemotherapy orders increased so too did the number of near-miss medication errors. To minimize medication errors, the hospital implemented the new role of a verification nurse (VN) to review all chemotherapy orders. If a discrepancy is noted in the chemotherapy order, VNs investigate the incident by referring to protocols, contacting the health care provider for clarification, referring to the patient's plan of care for updates or changes and maintaining open and ongoing communication with the team members. Evaluation of the new role noted a direct correlation between an increase in chemotherapy orders and patient volume with error recovery by VNs. While additional complexity added to an increased number of medical errors, the organization embraced the concept of error recovery. This is an example of how one hospital heightened their sense of vigilance and supported strategies to enable health care providers to anticipate and detect problems early to prevent adverse events.

## **Conflict of interest**

The author has no real or perceived conflicts of interest.

*Nursing - New Perspectives*

## **Author details**

Theresa A. Gaffney Marymount University, Arlington, Virginia, USA

\*Address all correspondence to: tgaffney@marymount.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**43**

2000

*Keeping Patients Safe: The Critical Role of Medical Error Recovery*

[9] Helmreich R. On error management: Lessons from aviation. BMJ. 2000;**320**:

[10] Latorella K, Prabhu P. A review of human error in aviation maintenance and inspection. International Journal of Industrial Ergonomics. 2000;**26**:133-161

[11] Airbus. Management flight operations briefing notes [Internet]. Available from: http://www.smartcockpit.com/docs/ Error\_Management.pdf [Accessed:

[12] Patel V. Failure to detect medical error [Internet]. 2010. Available from: https://www.youtube.com/ watch?v=jkIrFxDBqKk [Accessed:

[13] Habraken MP, van der Schaaf TW. If only....: Failed, missed and absent error recovery opportunities in medication errors. Quality & Safety in Health Care. 2010;**1**:37-41. DOI: 10.1136/

[14] Agency for Healthcare Research and Quality. High reliability [Internet]. 2019. Available from: https://www.psnet.ahrq. gov/primer/high-reliability [Accessed:

[15] Henneman EA, Gawlinski A. A "near-miss" model for describing the nurse's role in the recovery of medical errors. Journal of Professional Nursing.

[16] Gaffney T, Hatcher B, Milligan R. Nurses' role in medical error recovery: An integrative review. Journal of Clinical Nursing. 2016;**25**:906-917. DOI:

[17] van der Schaaf TW. Near miss reporting in the chemical process industry: An overview. Microelectronics and Reliability. 1995;**9-10**:1233-1243. DOI: 10.1016/0026-2714(95)99374-R

781-785

08 November 2019]

08 November 2019]

qshc.2007.026187

07 November 2019]

2004;**3**:196-201

10.111/jocn.13126

*DOI: http://dx.doi.org/10.5772/intechopen.91412*

[1] World Health Organization. WHO calls for urgent action to reduce patient harm in healthcare [Internet]. 2019. Available from: https://www.who.int/ news-room/detail/13-09-2019-whocalls-for-urgent-action-to-reducepatient-harm-in-healthcare [Accessed:

[2] The Betsy Lehman Center for Patient Safety. The financial and human cost of medical error [Internet]. 2019. Available from: https://betsylehmancenterma. gov/assets/uploads/Cost-of-Medical-Error-Report-2019.pdf [Accessed:

[3] Carthey J, de Leval M, Reason J. Institutional resilience in healthcare systems. BMJ Quality and Safety. 2001;**10**:29-32. DOI: 10.1136/qhc.10.1.29

[4] Leape L. A systems analysis approach to medical error. Journal of Evaluation in Clinical Practice. 1997;**3**:213-222

[5] Reason J. Human error: Models and management. BMJ (Clinical Research

[6] Institute of Medicine (U.S.). To Err Is Human: Building a Safer Health System. Washington: National Academies Press;

[8] Agency for Healthcare Research and Quality. AHRQ analysis finds hospitalacquired conditions declined by nearly 1 million from 2014-2017 [Internet]. 2019. Available from: https://www.ahrq. gov/news/newsroom/press-releases/ hac-rates-declined.html [Accessed:

[7] Classen D, Resar R, Griffin F, Frederico F, Frankel T, Kimmel N, et al. Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. 2011;**30**:581-589. DOI:

10.1377/hlthaff.2011.0190

08 November 2019]

Ed.). 2000;**7237**:768-770

**References**

08 November 2019]

08 November 2019]

*Keeping Patients Safe: The Critical Role of Medical Error Recovery DOI: http://dx.doi.org/10.5772/intechopen.91412*

## **References**

*Nursing - New Perspectives*

**42**

**Author details**

Theresa A. Gaffney

Marymount University, Arlington, Virginia, USA

provided the original work is properly cited.

\*Address all correspondence to: tgaffney@marymount.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

[1] World Health Organization. WHO calls for urgent action to reduce patient harm in healthcare [Internet]. 2019. Available from: https://www.who.int/ news-room/detail/13-09-2019-whocalls-for-urgent-action-to-reducepatient-harm-in-healthcare [Accessed: 08 November 2019]

[2] The Betsy Lehman Center for Patient Safety. The financial and human cost of medical error [Internet]. 2019. Available from: https://betsylehmancenterma. gov/assets/uploads/Cost-of-Medical-Error-Report-2019.pdf [Accessed: 08 November 2019]

[3] Carthey J, de Leval M, Reason J. Institutional resilience in healthcare systems. BMJ Quality and Safety. 2001;**10**:29-32. DOI: 10.1136/qhc.10.1.29

[4] Leape L. A systems analysis approach to medical error. Journal of Evaluation in Clinical Practice. 1997;**3**:213-222

[5] Reason J. Human error: Models and management. BMJ (Clinical Research Ed.). 2000;**7237**:768-770

[6] Institute of Medicine (U.S.). To Err Is Human: Building a Safer Health System. Washington: National Academies Press; 2000

[7] Classen D, Resar R, Griffin F, Frederico F, Frankel T, Kimmel N, et al. Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. 2011;**30**:581-589. DOI: 10.1377/hlthaff.2011.0190

[8] Agency for Healthcare Research and Quality. AHRQ analysis finds hospitalacquired conditions declined by nearly 1 million from 2014-2017 [Internet]. 2019. Available from: https://www.ahrq. gov/news/newsroom/press-releases/ hac-rates-declined.html [Accessed: 08 November 2019]

[9] Helmreich R. On error management: Lessons from aviation. BMJ. 2000;**320**: 781-785

[10] Latorella K, Prabhu P. A review of human error in aviation maintenance and inspection. International Journal of Industrial Ergonomics. 2000;**26**:133-161

[11] Airbus. Management flight operations briefing notes [Internet]. Available from: http://www.smartcockpit.com/docs/ Error\_Management.pdf [Accessed: 08 November 2019]

[12] Patel V. Failure to detect medical error [Internet]. 2010. Available from: https://www.youtube.com/ watch?v=jkIrFxDBqKk [Accessed: 08 November 2019]

[13] Habraken MP, van der Schaaf TW. If only....: Failed, missed and absent error recovery opportunities in medication errors. Quality & Safety in Health Care. 2010;**1**:37-41. DOI: 10.1136/ qshc.2007.026187

[14] Agency for Healthcare Research and Quality. High reliability [Internet]. 2019. Available from: https://www.psnet.ahrq. gov/primer/high-reliability [Accessed: 07 November 2019]

[15] Henneman EA, Gawlinski A. A "near-miss" model for describing the nurse's role in the recovery of medical errors. Journal of Professional Nursing. 2004;**3**:196-201

[16] Gaffney T, Hatcher B, Milligan R. Nurses' role in medical error recovery: An integrative review. Journal of Clinical Nursing. 2016;**25**:906-917. DOI: 10.111/jocn.13126

[17] van der Schaaf TW. Near miss reporting in the chemical process industry: An overview. Microelectronics and Reliability. 1995;**9-10**:1233-1243. DOI: 10.1016/0026-2714(95)99374-R

[18] Kessels-Habraken M, van der Schaaf TW, de Jong J, Rutte C. Defining near misses: Toward a sharpened definition based on empirical data about error handling processes. Social Science & Medicine. 2010;**70**:1301-1308

[19] van der Schaaf TW, Kanse L. Errors and Error Recovery. In: Elzer PF, Kluwe RH, Boussoffara B, editors. Human Error and System Design and Management. Godalming: Springer; 2000

[20] Henneman EA, Blank F, Gawlinski A, Henneman P. Strategies used by nurses to recover medical errors in an academic emergency department setting. Applied Nursing Research. 2006;**2**:70-77

[21] Henneman EA, Gawlinski A, Blank F, Henneman P, Jordan D. MKJ. Strategies used by critical care nurses to identify, interrupt, and correct medical errors. American Journal of Critical Care. 2010;**6**:500-509. DOI: 10.4037/ ajcc2010167

[22] Yang Y, Henry L, Dellinger M, Yonish K, Emerson B, Seifert PC. The circulating nurse's role in error recovery in the cardiovascular OR. AORN Journal. 2012;**6**:755-762

[23] Odukoya O, Stone J, Chiu M. How do community pharmacies recover from e-prescription errors? Research in Social & Administrative Pharmacy. 2014;**10**:837-852. DOI: 10.1016/j. sapharm.2013.11.009

[24] Henneman EA. Recognizing the ordinary as extraordinary: Insight into the "way we work" to improve patient safety. American Journal of Critical Care. 2017;**26**:272-276. DOI: 10.4037/ ajcc2017812

[25] Dykes PC, Rothschild JM, Hurley AC. Medical errors recovered by critical care nurses. The Journal of Nursing Administration. 2010;**5**:241-246 [26] Rothschild J, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA, et al. Medication errors recovered by emergency department pharmacists. Annals of Emergency Medicine. 2010;**55**:513-521. DOI: 10.1016/j.annemergmed.2009.10.012

[27] Benjamin J, Cox E, Trapskin P, Rajamanickam V, Jorgenson R, Weber H, et al. Family-initiated dialogue about medications during family-centered rounds. Pediatrics. 2015;**1**:135-194. DOI: 10.1542/peds.2013-3885

[28] Lang S, Garrido MV, Heintze C. Patients' view of adverse events in primary and ambulatory care: A systematic review to assess methods and the content of what patients consider to be adverse events. BMC Family Practice. 2016;**17**. DOI: 10.1186/ s12875-016-0408-0

[29] Gillespie A, Reader T. Patient-centered insights: Using healthcare complaints to reveal hotspots and blindspots in quality and safety. The Milbank Quarterly. 2018;**96**(3):530-567. DOI: 10.1111/1468-0009.12338

[30] Ambrose S, Bridges M, DiPietro M, Lovett M, Norman M. How Learning Works. San Francisco CA: Jossey-Bass; 2010

[31] Gaffney T, Hatcher B, Milligan R, Trickey A. Enhancing patient safety: Factors influencing medical error recovery among medical-surgical nurses. Online Journal of Issues in Nursing. 2016;**23**(3):1-12

[32] Leonard D, Swap W. Deep Smarts. Boston: Harvard School Press; 2005

[33] Patel VL, Cohen T, Murarka T, Olsen J, Kagita S, Myneni S, et al. Recovery at the edge of error: Debunking the myth of the infallible expert. Journal of Biomedical Informatics. 2011;**44**:413-424

**45**

pp. 39-51

*Keeping Patients Safe: The Critical Role of Medical Error Recovery*

*DOI: http://dx.doi.org/10.5772/intechopen.91412*

[34] Wilkinson W, Cauble L, Patel V. Error detection and recovery in dialysis nursing. Journal of Patient Safety.

[35] Kahol K, Vankipuram M, Patel VL, Smith ML. Deviations from protocol in a complex trauma environment: Errors or innovations. Journal of Biomedical Informatics. 2011;**44**:425-431. DOI:

[36] Guastello S, Correro A, Marra D. Cusp catastrophe models for cognitive workload and fatigue in teams. Applied Ergonomics. 2019;**79**:152-168. DOI: 10.1016/j.apergo.2018.08.019

[37] Redding D, Robinson S. Interruptions and geographic challenges to nurses' cognitive workload. Journal of Nursing Care Quality. 2009;**24**(3):194-200

[39] Patel V, Kannampallil T, Shortliffe E. Role of cognition in generating and mitigating clinical errors. BMJ Quality and Safety. 2015;**24**:468-474. DOI: 10.1136/bmjqs-2014-003482

[40] Amalberti R, Vincent C. Managing

[41] Baldwin A, Rodriguez E. Improving patient safety with error identification in chemotherapy orders by verification nurses. Clinical Journal of Oncology Nursing. 2016;**20**(1):59-66. DOI:

risk in hazardous conditions: Improvisation is not enough. BMJ Quality and Safety. 2020;**29**:60-63. DOI:

10.1136/ bmjqs-2019-009443

10.1188/16.CJON.59-65

[38] Potter P, Wolf L, Boxerman S, Grayson D, Sledge J, Dunagan C, et al. An analysis of nurses' cognitive work: A new perspective for understanding medical error. In: Henriksen K, Battles JB, Marks ES, et al, editors. Advances in Patient Safety: From Research to Implementation. Vol. 1. Washington, DC: Agency for Healthcare Research and Quality (US); 2005.

2011;**7**:213-223

10.1016/j.jbi.2011.04.003

*Keeping Patients Safe: The Critical Role of Medical Error Recovery DOI: http://dx.doi.org/10.5772/intechopen.91412*

[34] Wilkinson W, Cauble L, Patel V. Error detection and recovery in dialysis nursing. Journal of Patient Safety. 2011;**7**:213-223

*Nursing - New Perspectives*

[18] Kessels-Habraken M, van der Schaaf TW, de Jong J, Rutte C. Defining near misses: Toward a sharpened

& Medicine. 2010;**70**:1301-1308

[19] van der Schaaf TW, Kanse L. Errors and Error Recovery. In: Elzer PF, Kluwe RH, Boussoffara B, editors. Human Error and System Design and Management. Godalming: Springer;

[20] Henneman EA, Blank F,

Gawlinski A, Henneman P. Strategies used by nurses to recover medical errors in an academic emergency department setting. Applied Nursing Research.

[21] Henneman EA, Gawlinski A, Blank F, Henneman P, Jordan D. MKJ. Strategies used by critical care nurses to identify, interrupt, and correct medical errors. American Journal of Critical Care. 2010;**6**:500-509. DOI: 10.4037/

[22] Yang Y, Henry L, Dellinger M, Yonish K, Emerson B, Seifert PC. The circulating nurse's role in error recovery in the cardiovascular OR. AORN

[23] Odukoya O, Stone J, Chiu M. How do community pharmacies recover from e-prescription errors? Research in Social & Administrative Pharmacy. 2014;**10**:837-852. DOI: 10.1016/j.

[24] Henneman EA. Recognizing the ordinary as extraordinary: Insight into the "way we work" to improve patient safety. American Journal of Critical Care. 2017;**26**:272-276. DOI: 10.4037/

[25] Dykes PC, Rothschild JM, Hurley AC. Medical errors recovered by critical care nurses. The Journal of Nursing Administration. 2010;**5**:241-246

Journal. 2012;**6**:755-762

sapharm.2013.11.009

ajcc2017812

2000

2006;**2**:70-77

ajcc2010167

definition based on empirical data about error handling processes. Social Science

[26] Rothschild J, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA, et al. Medication errors recovered by emergency department pharmacists. Annals of Emergency Medicine. 2010;**55**:513-521. DOI: 10.1016/j.annemergmed.2009.10.012

[27] Benjamin J, Cox E, Trapskin P, Rajamanickam V, Jorgenson R, Weber H, et al. Family-initiated dialogue about medications during family-centered rounds. Pediatrics. 2015;**1**:135-194. DOI:

Heintze C. Patients' view of adverse events in primary and ambulatory care: A systematic review to assess methods and the content of what patients consider to be adverse events. BMC Family Practice. 2016;**17**. DOI: 10.1186/

10.1542/peds.2013-3885

[28] Lang S, Garrido MV,

s12875-016-0408-0

[29] Gillespie A, Reader T. Patient-centered insights: Using healthcare complaints to reveal hotspots and blindspots in quality and safety. The Milbank Quarterly. 2018;**96**(3):530-567. DOI:

10.1111/1468-0009.12338

Nursing. 2016;**23**(3):1-12

2010

[30] Ambrose S, Bridges M, DiPietro M, Lovett M, Norman M. How Learning Works. San Francisco CA: Jossey-Bass;

[31] Gaffney T, Hatcher B, Milligan R, Trickey A. Enhancing patient safety: Factors influencing medical error recovery among medical-surgical nurses. Online Journal of Issues in

[32] Leonard D, Swap W. Deep Smarts. Boston: Harvard School Press; 2005

[33] Patel VL, Cohen T, Murarka T, Olsen J, Kagita S, Myneni S, et al. Recovery at the edge of error: Debunking the myth of the infallible expert. Journal of Biomedical Informatics. 2011;**44**:413-424

**44**

[35] Kahol K, Vankipuram M, Patel VL, Smith ML. Deviations from protocol in a complex trauma environment: Errors or innovations. Journal of Biomedical Informatics. 2011;**44**:425-431. DOI: 10.1016/j.jbi.2011.04.003

[36] Guastello S, Correro A, Marra D. Cusp catastrophe models for cognitive workload and fatigue in teams. Applied Ergonomics. 2019;**79**:152-168. DOI: 10.1016/j.apergo.2018.08.019

[37] Redding D, Robinson S. Interruptions and geographic challenges to nurses' cognitive workload. Journal of Nursing Care Quality. 2009;**24**(3):194-200

[38] Potter P, Wolf L, Boxerman S, Grayson D, Sledge J, Dunagan C, et al. An analysis of nurses' cognitive work: A new perspective for understanding medical error. In: Henriksen K, Battles JB, Marks ES, et al, editors. Advances in Patient Safety: From Research to Implementation. Vol. 1. Washington, DC: Agency for Healthcare Research and Quality (US); 2005. pp. 39-51

[39] Patel V, Kannampallil T, Shortliffe E. Role of cognition in generating and mitigating clinical errors. BMJ Quality and Safety. 2015;**24**:468-474. DOI: 10.1136/bmjqs-2014-003482

[40] Amalberti R, Vincent C. Managing risk in hazardous conditions: Improvisation is not enough. BMJ Quality and Safety. 2020;**29**:60-63. DOI: 10.1136/ bmjqs-2019-009443

[41] Baldwin A, Rodriguez E. Improving patient safety with error identification in chemotherapy orders by verification nurses. Clinical Journal of Oncology Nursing. 2016;**20**(1):59-66. DOI: 10.1188/16.CJON.59-65

**47**

**Chapter 4**

**Abstract**

**1. Introduction**

and the fall in their indicators.

Patient Safety in a First-Level

*Yaqueline Churi Antero, Yudi Nathalia Angulo Ante* 

safety culture, which means that adverse events are not documented.

**Keywords:** MeSH and DeCS, adverse event, preventable adverse event, Non-preventable adverse event, London protocol, patient safety policy

Health care over time has become a complex and very careful act, which, in addition to providing users with adequate treatment for their health problems, represents a latent risk since it can cause involuntary damage. This, for obvious reasons, since 2002 the World Health Organization (WHO), requested in Resolution WHA55.18 the member states to pay as much attention as possible to the problem of patient safety [1]. This difficulty being an attenuator over time has become a public health problem that directly impacts the quality of care of users of health services

This World Alliance, which aims to coordinate, disseminate, and accelerate the improvement of patient safety worldwide, is a means that fosters international collaboration and the adoption of measures among member states, the WHO secretariat, the technical experts and consumers, professionals, and industrial groups [2]. Different studies conducted in our country at different levels of care, such as

to London Protocol

*Carmen Luisa Betancur Pulgarín,* 

*and Diego Carmona Carmona*

Hospital in Colombia, According

*Mónica Roció Romero Carvajal, Luis Gabriel Murillo Micolta,* 

The objective of this study is to identify the adherence of the health personnel of the state social enterprise Norte 2 institution, Caloto, Department of Cauca, Colombia, in the application of the London protocol, referring to patient safety policy, where a quantitative investigation was conducted; observational, descriptive through a census of 92 officials of the institution through a survey designed to measure adherence to protocol, all information was tabulated in the Epi-info 7.2 program and presented by descriptive statistics; the results of this study showed that the population is composed of 60% of female nursing assistants who are more than 1-year old and that the protocol is partially met, where it was found that only 52% of adverse events are reported, concluding that there is no defined patient

## **Chapter 4**
