“Over 300 studies have shown that health information cannot be understood by most of the people for whom it was intended, suggesting that the assumptions made by the creators of this information, regarding the recipient’s level of health literacy, are often incorrect.” (Youngberg, 2011, pg. 407-410). This is a very serious topic, regarding patient safety. The information that leaves with patients post and prior to a visit should be explained and thoroughly understood before being let out of care. For example, An illiterate patient, who misunderstands the doctors instructions for their prescription and takes their blood thinner wrongly could bleed out. Also, look at a mother who was not properly informed and gives their new born an oral prescription through the child’s ear canals. These are all very serious actions and could have terrible ramifications. (Youngberg, 2011, pg. 409). These misunderstandings could happen from wording being too difficult for some to understand, or even if a patient speaks a different primary language other than how the health information was relayed.
A second example of poor risk management is poor quality hand offs within a health organization. Handoffs are basically the exchange of information from one care giver, physician, or one department to the next. This is very important aspect to keep track of. Imagine if medications, past treatments and procedures were not mentioned to a patient being transferred from the floor to an ICU or to a completely new facility. Certain conditions and complications need to be treated in a certain way so it’s important to have a background on whats been done. This could lead to exams being done multiple times, or a delay in care by having to track info down. (Youngberg, 2011, pg 443). There are methods to keep track of patients in a hospital, one example, is an SBAR. The information kept in this tracks the patient’s situation, background, assessment and recommendations. (Youngberg, 2011, pg 446).
Finally, fatigue of the health care worker can have very adverse effects to the patients they are giving care to. Fatigue is something that is different for everyone in certain ways but one thing is for sure, it can happen to anyone if they are not treating their body right. Employees need to be able to balance their professional and work life in order to not become fatigued. “Fatigue usually presents when a person is suffering from lack of quality sleep that, over time, can adversely affect performance.” (Youngberg, 2011, pg. 424). I think one way to prevent fatigue from happening is being properly staffed within departments. It is hard for employees to work long hours and turn around the next day and do it all over again. An easy example of this is someone who works an evening shift and also has to work early the next morning, the turn around is only a few hours and can lead to forgetfulness and sluggishness the next day. Unfortunately, this is a scenario that happens all too often in health care and this could be due to unexpected illness or various other reasons like a family emergency, perhaps. Proper staffing or extra staffing, like from PRN’s or part timers, would help alleviate this type of issue.
Youngberg, B. (2011). Principles of risk management and patient safety. Sudbury, MA: Jones and Bartlett Publishers.