Critical Essay On Human Error In Healthcare System Nursing Essay

Critical Essay On Human Error In Healthcare System Nursing Essay The potentially devastating consequences of accidents means the NHS has a clear mandate to prioritise medical error reduction, whilst utilising energy, attention, and creativity towards delivering high-performance, high-confidence healthcare (DoH, 2000). The application of psychological theories of human action and error has an important part to play within this endeavour, not least because they exceed the merely descriptive, instead combining cognitive, affective and behavioural considerations to provide more integrated understandings of patient safety issues (Parker Lawton, 2006). Indeed, according to Zhang and colleagues (2002, p.75) medical error is primarily an issue for cognitive scienceà ¢Ã¢â€š ¬Ã‚ ¦not for medicine. Psychology has a long and distinguished tradition of discerning the nature and sources of human error (e.g., Broadbent, 1958; Rasmussen, 1990; Reason, 2000) and, in terms of patient safety, researchers are increasing recognising that appreciating such mechanisms is a vital prerequisite for devising suitable remediation (Parker Lawton, 2003, 2006). One important distinction in this regard is between the concept of slips/lapses (a sound plan, poorly executed), mistakes (an inappropriate plan, correctly implemented) and violations (a deliberate deviation from recommended practice). In contrast to the latter, which are generally intentional, slips/lapses and mistakes are primarily driven by failures in cognitive processing, and are therefore amenable to interventions based on knowledge acquisition, skills enhancement, and information provision (Lawton, 1998). It is these particular principles that form the basis of this review. Practitioner Errors Error in the health industry is ubiquitous, and the capacity for mistakes within even routine medical procedures is considerable (Bogner, 2004a). For example, a sobering compilation by Van Cott (1994) identified medication/anesthesia administration, laboratory testing, blood transfusions, diagnostic screening and the operation of medical technology as regular candidates for both incident reporting and malpractice claims. However, while healthcare providers conventionally emphasised refining technical proficiencies, appreciating the intricacy of staffs cognitive performance (and developing strategies to augment it) has a greater likelihood of enhancing safety (Hudson, 2003; Looseley et al., 2009; Zhang et al., 2004). According to Casey (1993, p.9) the individual as an independent system (i.e., unhampered by any kind of technology) is actually remarkably reliable; conversely, error likelihood is amplified by incompatibilities between the characteristics of peopleà ¢Ã¢â€š ¬Ã‚ ¦and the characteristics of the things we create and use. Applying psychological principles within healthcare systems has shown that working conditions, conventions, and procedures can be tailored to complement what we know about human behaviour, and that this wisdom can be utilised in a corrective way. Psychological research within other high-risk industries demonstrates that while mental operations often function beyond voluntary control, it is both possible and desirable to modify conditions in which staff perform (Green, 2004; Raab et al., 2006; Wilf-Miron et al., 2003). For example, McCulloch and colleagues (2009) designed an intervention derived from aviation-style Crew Resource Management coaching, implemented in the o perating theatre of a UK teaching hospital. The programme, comprised of teamwork skills, safety attitudes and performance training, was associated with significant reductions in operative technical errors and non-operative procedural errors. Similar results have been reported by Haller et al. (2008), who found that aviation-style training contributed to a significant improvement in multidisciplinary teamwork and organisational safety culture. In contrast, Rogers and colleagues (2004) advocate designing nurses work-shift cycles in concordance with current psychological knowledge about the impact of sleep disruption on acuity and performance, whereas Laschinger and Finegan (2005) suggest using empowerment principles derived from organisational psychology (e.g., workplace trust, respect, and justice) to motivate staff to lend their energy and expertise to prioritising patient safety. In more cognitive terms, Valenstein (2008) used tenets from the psychology of perception (e.g., optimized information density, ease of transfer, maximized fidelity/speed) to devise strategies for pathologists to format surgical reports in a manner that communicates most effectively and limits the chance of misinterpretation. Similarly, Shojania (2002) suggests that research inspired both by cognitive psychology and accident investigation within other industries provides the raw materials for predicting errors, recording critical incidents, and r eacting to them in a proactive, non-punitive manner. According to Reason (1994, p.ix) blaming fallible individualsà ¢Ã¢â€š ¬Ã‚ ¦is universal, natural, emotionally satisfying and legallyà ¢Ã¢â€š ¬Ã‚ ¦convenient. Unfortunately it has little or no remedial value  [1]  . One of the most basic principles of error management that transitory mental states like preoccupation, disorientation, and distraction are mostly inadvertent and hugely variable has been guided by psychological research into human performance that emphasise the necessity of systems-based approaches which identify latent organisational failures in addition to active individual errors (Bogner, 2004b). Medical systems incorporate vast, intricate arrays of disparate and semi-autonomous components, operating within variable, diffused and unpredictable circumstances. Indeed, according to Van Cott (1994, p.55) of all sociotechnical systems [healthcare delivery]à ¢Ã¢â€š ¬Ã‚ ¦is the largest, most complex, most costly and, in some respects, the most unique. Furthermore, it is grounded within a person-centred, person-driven system, with human operators its most ubiquitous and valuable element. Using the science of human thought and behaviour to enhance and refine human performance therefore appears a profitable way of pursuing healthcare quality and safety. Patient Errors Poor adherence to self-administered medical interventions is a pervasive, wide-ranging problem which compromises the efficacy of prescribed healthcare, squanders therapeutic resources and, most seriously, potentially endangers patient well-being (Park et al., 2004; Roter et al., 1998; Thomas, 2009). Research suggests that at least 50% of patients fail to receive the full benefit of therapeutic recommendations (e.g., preventative practices, medication regimens, lifestyle modification) due to inadequate observance of medical advice (Morisky et al., 2009), whereas up to 30% use drug prescriptions in a manner that poses a serious risk to health (Schmittdiel et al., 2008). Both conceptually and methodologically, medical compliance raises complex issues for patients and providers, meaning that a careful consideration of the problem is necessary before significant and meaningful enhancements in adherence (and consequent health status) can be achieved (Haynes et al., 1996). An important contribution from psychology for precluding self-care errors is a systematic understanding of the cognitive changes that may provoke them. Specifically, memory and comprehension deficits are a manifest cause of poor compliance (Park et al., 2004). This is particularly prevalent in terms of age-related cognitive decline, although even younger adults with high cognitive functioning are not exempt from the kind of intellective impairments that thwart the ability to attend to ones medical needs. This is consistent with the well-established finding that declines in cognitive ability are gradual, continuous and linear across the adult lifespan (Baltes Lindenberger, 1997). For example, medical errors in elderly individuals may be partly generated by deteriorations in processing speed, working memory and long-term recall (Davis et al., 2010; Hayes et al., 2009; Stoehr et al., 2008), which impede the ability to both encode and retrieve unfamiliar medical regimens, or to incorpor ate them into a treatment plan compatible with daily routine. In contrast, deficits in time-based prospective memory (Woods et al., 2009), working memory (Smith, 2007), and source memory (Park et al., 2004) can compromise the capacity of younger adults to adequately self-manage medical recommendations, an effect exacerbated amongst those who are inexperienced healthcare consumers (Park, 1999), or who are subject to excessive distraction, stress or fatigue (Stilley et al., 2010). Similarly, the illusion of truth effect, whereby statement repetition heightens perceived truth (Begg, 1992), is a powerful memory distortion to which adults of all ages are susceptible, and which can be dangerous in the medical realm if false information is remembered as true (for example, a conscientious clinician who repeatedly extols the futility of herbal remedies for diabetes may risk her patient paradoxically recalling herbal remedies as advantageous, due to failures in context-dependent memory: Park et al., 2004). In response to this, psychological research has informed a range of interventions to reduce medical self-management errors. For example, providing older adults with novel information in written form promotes assimilation through decreasing burdens on working memory (Tsai, 2006), whereas comprehension and decision-making can be enhanced through environmental supports like audiovisual materials, telephone instruction, and follow-up sessions with a healthcare provider (Myers Midence, 1998). Cognitive resources may also be supplemented with contextual supports, which help consolidate memory for health communications at the time of encoding and retrieval for patients of all ages. For example, simplified treatment regimens, or those that are conveniently tailored to daily habits (Smith, 2007), medication organizers and reminder pill packaging/prescription refills (Petersen et al., 2007), supportive home visits (Kripalani et al., 2007), behavioural contracting and modelling (Christensen J ohnson, 2002), text-message prompts (Matsui, 2009), and electronic beepers (Kalichman, 2005), have all been shown to consistently enhance treatment adherence, with subsequent improvements in treatment outcomes. A considerable benefit of all these strategies is that they employ resources that are readily accessible within clinical settings. Conclusions According to Rasmussen (1994, p.392) patient safety is a frontier for change. An important aspect of this process is effective transfer of research themes into clinical practice. While psychological approaches have facilitated enhanced performance and learning at both organisational and individual levels, ensuring such improvements remain sustained and intentional is a complex task. Successful diffusion of evidence-based interventions to real-world applications requires prudent planning, implementation, and evaluation in order that healthcare quality can be constantly revised and refined. For example, inadequate understandings of the theoretical processes implicated in behaviour change means evidence-based guidelines are often poorly implemented within medical settings (Michie et al., 2005), while the intense rapidity and intricacy of change within healthcare means conflict can exist between academics seeking to develop and refine theories, and the more immediate, practical need of p ractitioners seeking information on which to develop interventions. In this respect, a promising area for development is increased multidisciplinary working, not only in terms of partnerships between practitioners and psychologists, but in the active involvement and recruitment of patients themselves (DoH, 2005). Collaboration can be seen as the coming together of diverse interests and people to achieve a common purpose via interactionsà ¢Ã¢â€š ¬Ã‚ ¦and coordination of activities(Jassawalla Sashittal, 1998, p.239), with such alliances potentially facilitating the merging of science and practice through enhanced information-sharing, formulating accessible and meaningful research questions, developing shared visions of patient safety, and designing/disseminating interventions using appropriate materials and methods for practitioner/patient needs. As Carr and Kemmis (1996, p.165) observe, within this aspiration is: Improvement of a practice of some kindà ¢Ã¢â€š ¬Ã‚ ¦improvement of the understanding of a practiceà ¢Ã¢â€š ¬Ã‚ ¦andà ¢Ã¢â€š ¬Ã‚ ¦the improvement of the situation in which the practice takes placeà ¢Ã¢â€š ¬Ã‚ ¦Those involved in the practice being considered are to be involved inà ¢Ã¢â€š ¬Ã‚ ¦all its aspects of planning, acting, observing and reflecting for optimum results. 1782=1727

Beatrix Potter

Beatrix Potter was known from her literary woks that deal with the formation of ideal minds of children. Her children stories made significant prints in the world of literature. Through this, Potter became famous and influential in different parts of the world in terms of her writings and contributions to literature.Potter was born in South Kensington, London on July 28, 1866. She was not able to experience a normal and meaningful life during her childhood. Every action were detailed and numbered. She could not have more time to interact or communicate with other people.Only her pets became her friends as she kept them, studied about them, and draw them. Despite of this, she was luck for she was not a poor child like other authors or writers who seemed to start from rugs to riches. During her teenage years, she was introduced to many prominent personalities that gave her the opportunity to show her talent in writing and painting. Because she was unhappy with her childhood life, she s hared her talent to the children whom she wanted to imagine, to amaze, to laugh, or to simply become happy.Another factor that manifest in her literary works was her love for animals. Her first children story was about an animal. Her story book was filled with animal pictures along with a simple story to make a child happy. This was happen in 1892, when she started to create a children short story. She sent her story to her friends’ son. Soon, this piece became the â€Å"tale of Peter Rabbit† in 1920. This story was her first and major published work that many children used to read until today. After a year, another story was published with the help of her friends and family.Yearly, she publicized one to two stories that became famous and significant in different parts of the world during her time and until today, which can still be seen in the future. Most of her topics in her stories are about animals and vegetables because for her, it can be a way for children to be come more familiar and close to their pets and other animals as well as their eating habit when it comes to eating vegetables. Along with her writing stories, she also paints different kinds of paintings. Though those paintings are simple, they still bring life to the many people.As she started her first story in 1902, she worked for different stories that were published until 1944, a year after her death. However, though she stopped writing stories, she still wrote different letters as well as manuscripts whether personal or career manuscripts were not taken for granted. After her death on December 22 1943 at the age of 77, many authors and chroniclers had their way to give importance to the life and contribution of Potter. Her books have been translated to braille and numerous languages including German, Latin, Welsh, Spanish, French, Japanese and Dutch (Merriman, 2006).As many authors and writers’ way of giving gratitude and respect towards potter, they made her pieces rec ognized in different parts of the world by translating her text in different kinds of languages. Because of her contribution to literature, many authors of children stories patterned their pieces on Potter’s works for it can be seen as a way of nurturing children through the use of animal and vegetable characters. From this sense, many analysts have thought about the deeper sense of Potter’s attack to her writings.According to different analysts, Potter can be perceived as a conservationist for she helped environmentalists to publicize animal and plant affection through her writings. Beatrix Potter was not only an accomplished writer and artist in watercolor; she was also an observant naturalist; a hard-headed but kindly farm manager; above all she was an ardent conservationist (Diaz, 2007). She was also perceived as a potential botanist from her short stories as she transcends the life and essence of animal and plant characterization.Aside from writing and illustratin g children's books, Beatrix Potter created precise, realistic botanical drawings and paintings, which she wished to be used to illustrate scientific books on flora and fauna. (Literary Traveler, 2008). She also discussed the preservation of natural resources in a simpler yet attackable concept that children would understand. For her, because children are easy to educate, they were became her prospect to a further change on the environment. Another significant reason why Beatrix Potter became famous is because she used to writer her stories through coding.She used to write by using her own code that only she as the writer of her stories can understand the meaning of her writings. Through this, many writers, authors, analysts, and critics tried to understand the capabilities and attacks of Potter in her writings by using her code. For her, her code became her secret to provide good writing and classification of manner to formulate for children’s young minds and justifications. Another artistic pursuit for the teenage Potter was writing a journal in a code no-one could read.The Journal of Beatrix Potter 1881-1897 (first published by Frederick Warne in 1966) is part of this document, transcribed from code by Potter scholar Leslie Linder. She kept this type of journal until the age of 30 (Literary Traveler, 2008). It was seen that it was a phenomenon style that few writers or authors could do. it can be said that Potter has her own strategy to formulate her own thoughts to create stories for children. In conclusion to this, Beatrix Potter was not just a simple writer and painter during her lifetime.She made some difference in her period that is significant until today. Her literary pieces brought different light in science as well as humanity. Her secret code was also made to produce her passion for children stories without any proportion of unjustified claims and arguments from other people. It was revealed that by using her own code, Potter had a personali ty that she wanted to be along and would close her door from others. She made her own wall to separate herself from the other.It created positive impact on her writings but not on her personality and being for she remained single until she died. Works Cited Diaz, Rony. 2007. â€Å"Center for Gravity: Miss Potter. † The Manila Times. 3 February 2008. http://www. manilatimes. net/national/2007/apr/15/yehey/opinion/20070415opi2. html Frederick Warne & Co. 2007. â€Å"Beatrix Potter: A Life in Nature. † 3 February 2008. http://www. bpotter. com/? v1=BeatrixPotter&v2=Writings Kutzer, Daphne. Beatrix Potter: Writing in Code (Children's Literature and Culture, 27).Routledge Publishing, 2002. Literary Traveler. 2008. â€Å"Beatrix Potter – More Than Just Bunnies: The Legacy of Beatrix Potter. † 3 February 2008. http://www. literarytraveler. com/authors/beatrix_potter. aspx Merriman, C. D. 2006. â€Å"Beatirx Potter. † The Literature Network. 3 February 200 8. http://www. online-literature. com/beatrix-potter/ National Trust. 2008. â€Å"The Story of Beatrix Potter. † 3 February 2008. http://www. nationaltrust. org. uk/main/w-chl/w-places_collections/w-collections-main/w-collections-beatrix_potter/w-collections-feature_1-2. htm

Short Article Reveals the Undeniable Facts About Easy Argumentative Essay Topics on Dogs and How It Can Affect You

Short Article Reveals the Undeniable Facts About Easy Argumentative Essay Topics on Dogs and How It Can Affect You Each paragraph ought to be restricted to the discussion of one general idea. You need the strong personal opinion on this issue you intend to discuss in your argumentative essay. It is advised to steer clear of argument essay topics on moral issues because they don't support logical discussion. Selecting the very best topic for an argumentative essay is contingent on the circumstance and field of study. The Benefits of Easy Argumentative Essay Topics on Dogs It's far better to adopt a pet instead of getting it. There are lots of folks who don't need to understand what's in their food. For instance, to write about the impact of video games on child development isn't a great idea if you haven't ever played video games yourself. The first thing you're likely to have to do is to pick a topic that has more than one clear side. Top Easy Argumentative Essay Topics on Dogs Secrets In this kind of situation, it's more convenient to discover ready-made essays and use them as an example. Quite simply, attempt to think of a situation you'll argue about in your persuasive essay. At some stage, you're likely to be requested to compose an argumentative essay. When it has to do with writing an argumentative essay, the most crucial matter to do is to select a topic and an argument you can really get behind. An argumentative essay is among the many academic essay types. It requires you to decide on a topic and take a position on it. It is a type of essay that presents arguments about both sides of an issue. Every argumentative essay should depend on a topic that may be debated. If You Read Nothing Else Today, Read This Report on Easy Argumentative Essay Topics on Dogs No matter the quantity or kind of research involved, argumentative essays must set a very clear thesis and follow sound reasoning. An argumentative essay example will reveal the should possess some crucial components which make it better in the practice of convincing. It is essential that the thesis statement ought to be slimmed down to be able to adhere to the guidelines of the given writing exercise. A thesis statement is frequently the previous sentence in an introduction. Easy Argumentative Essay Topics on Dogs Can Be Fun for Everyone You ought to be able to settle on recent issues which are linked to society today. Writing about widespread problems like national or global problems is often unmanageable in just two or three pages. Without a fantastic evidence, nobody will believe my words. If you're searching for help, BibMe has a grammar check service you can test out. Life, Death, and Easy Argumentative Essay Topics on Dogs Argumentative essays are very typical in academic writing and are frequently a significant part writing in all disciplines. The argumentative essay has a certain format that should be followed to blow the mind of the reader, and it is particularly helpful for students along with the corporate whilst making strategic proposals. Writing a persuasive essay about animals may be difficult if you aren't provided a list of topics to think about. Take a look at this argumentative essay infographic! Then take a look at a list of argumentative essay advice to help you begin. Then you need to endeavour to select an appropriate argumentative essay format. By now you're probably eager to observe an exceptional argumentative essay outline template. Stick to the guide and get started writing your argumentative essay. Inspiration to make your own advertising or media argumentative essay topics isn't tricky to discover. No wonder, you might get lost in all that writing assignments which need to be done at the exact same time. You may continue to keep your argumentative essays for your upcoming job portfolio in case they're highly graded. Even when you're writing an informative essay, it's still true that you have the job of attempting to convince your audience that the info is vital. The Characteristics of Easy Argumentative Essay Topics on Dogs A debatable topic is one which has differing viewpoints. A conclusion is, without doubt, the most essential portion of the argumenta tive essay since you can either support the superior impression or destroy it entirely. A terrific conclusion will summarize all data that has happened in the guide and use it in order to give one final reason why you ought to join our side.

Citation and Reference List - 9582 Words

University of Sydney Business School Referencing Guide This referencing guide has been prepared by The Business Programs Unit for use in Units of Study within The University of Sydney Business School. It is based on the Harvard referencing style. Contents 1. How to use this guide...........................................................................................................................2 2. Some useful terms ...............................................................................................................................2 3. 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