Book contents
- Medication Safety during Anesthesia and the Perioperative Period
- Medication Safety during Anesthesia and the Perioperative Period
- Copyright page
- Dedication
- The Snow Vaporizer, Mark II
- Contents
- Foreword
- Acknowledgments
- 1 Introduction to Medication Safety in Anesthesia and the Perioperative Period
- 2 Failures in Medication Safety during Anesthesia and the Perioperative Period
- 3 Failures in Medication Safety in the Intensive Care Unit and Ward
- 4 Impact of Medication Errors on the Patient and Family
- 5 Consequences for the Practitioner
- 6 Why Failures Occur in the Safe Management of Medications
- 7 Errors in the Context of the Perioperative Administration of Medications
- 8 Violations and Medication Safety
- 9 Interventions to Improve Medication Safety
- 10 Medication Safety in Special Contexts
- 11 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part I: General Principles
- 12 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part II: Practical Examples
- 13 Barriers to Improving Medication Safety
- 14 Conclusions
- Index
- References
13 - Barriers to Improving Medication Safety
Why Is Patient Safety So Hard?
Published online by Cambridge University Press: 09 April 2021
Book contents
- Medication Safety during Anesthesia and the Perioperative Period
- Medication Safety during Anesthesia and the Perioperative Period
- Copyright page
- Dedication
- The Snow Vaporizer, Mark II
- Contents
- Foreword
- Acknowledgments
- 1 Introduction to Medication Safety in Anesthesia and the Perioperative Period
- 2 Failures in Medication Safety during Anesthesia and the Perioperative Period
- 3 Failures in Medication Safety in the Intensive Care Unit and Ward
- 4 Impact of Medication Errors on the Patient and Family
- 5 Consequences for the Practitioner
- 6 Why Failures Occur in the Safe Management of Medications
- 7 Errors in the Context of the Perioperative Administration of Medications
- 8 Violations and Medication Safety
- 9 Interventions to Improve Medication Safety
- 10 Medication Safety in Special Contexts
- 11 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part I: General Principles
- 12 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part II: Practical Examples
- 13 Barriers to Improving Medication Safety
- 14 Conclusions
- Index
- References
Summary
We have seen in Chapter 9 that we have many avenues to improve medication safety in anesthesia and the perioperative period, with considerable evidence and expert consensus to support them. However, human nature, just as it leads to errors, also often drives resistance to implementing safety interventions. Complicating our efforts to improve safety are safety paradoxes that, although would seem to improve safety, actually may work against safety. Achieving improved patient safety requires a deep understanding of not just how things go wrong when error-prone human beings work within complex systems but also why changes that would have a high probability of reducing the risk of errors are so often resisted. Needed changes can be resisted by individual physicians and by entire leadership of a large healthcare system. We return to the concept of violations, and emphasize that failure to hold violators accountable will effectively undermine safety efforts. Finally, an effort to understand why we do not change is absolutely imperative, as our continued refusal to change to safer methods continues to imperil our patients.
Keywords
Patient safetysafety paradoxHigh Reliability Organization normalizaiton of deviancesafety climaterisk displacementstandardizationautonomyteamworkcommunicationhandoffssafety culturepower distancehierarchydisrespecthumiliationshamingculture of respectpsychological safetyerror reportingwalk-araoundscost of safetyelectronic healt recordcomputerized order entryprefilled syringessafety programhuman natureviolationsguidelinesprotocolsvariations in healthcareexpert opinion
- Type
- Chapter
- Information
- Medication Safety during Anesthesia and the Perioperative Period , pp. 265 - 280Publisher: Cambridge University PressPrint publication year: 2021
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