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Patient Safety

No human being is perfect, meaning that in every field where humans are involved, there is bound to be the commission of an error, regardless of the level of experience or training of people involved. This situation is especially common in medical practice areas, whereby a study showed that human errors resulted in patient safety jeopardy that, in turn, caused up to 98,000 patient annual fatalities (Institute of Medicine [IOM], 1999). Such errors deny patients total safety, which the IOM (1999) defined as the state of being free from being injured accidentally. The patient safety issue in focus is a situation in which a patient fell on a slippery washroom floor while attempting to self-transfer from the wheelchair to the toilet seat. Evidence indicated that the patient did not have any shoes on, instead wearing only socks that caused them to slip and fall. However, this error did not result in any injury. The analysis of the error helps to identify its nature and propose several remedies that would prevent its recurrence.

Analysis of the Error

The error in question is clearly the fact that the patient was allowed to go to the washroom without assistance or being fully dressed in shoes to prevent them from slipping and falling. The care of such a patient falls in the domain of the role of the nursing staff who are supposed to ensure that patients are always operating within allowed safety margins (IOM, 2004). It follows then that one emergent cause of this accident was the error of negligence since responsible nurses did not monitor the patient appropriately and they were not with the patient when there was a need to visit the washroom. This case also falls under the preventive class of errors, as defined by the IOM, since it was due to inadequate monitoring. Therefore, it was primarily a process error as defined by the IOM (2004). If due process was followed, the patient should have been under the care of a nurse who would have assisted in the bathroom where the patient was self-transferring.

The safety issue of the patient falling in the bathroom is divisible into two levels; one being that the patient was allowed in the washroom without assistance or shoes, and the second being that the floor was designed to be slippery, which endangered the patient. Thus, the first level of the error is attributable to a lapse among the nursing staff. The IOM (1999) defines a lapse as an unobservable error that renders the staff member unable to execute the appropriate action. In this case, nurses in charge were not present and hence could not help when the patient needed them to assist in the bathroom, leading to the accident. In the same vein, the IOM (1999) defines latent errors as those that are removed from operators’ direct control, including such things as incorrect installation or poor design, which are called the blunt end. The design of the floor as slippery as it was contributed to the accident as much as the patient being alone did. Therefore, the poor design and the faulty decision that sanctioned this particular floor type are the latent errors that led to the accident.

Technical malfunction encompasses the failure of equipment to perform as designed or intended during a procedure or care, while human error is simply the inability of human beings involved in the care process to operate the present equipment within the set framework to deliver the appropriate care levels (IOM, 1999). For instance, if the wheelchair had broken down, causing the patient to fall, this would have qualified as a technical error. However, the accident in focus started with the architect who designed and constructed a slippery floor that exposed patients to fall risks, which the management approved. On the day of the accident, the responsible nursing staff were not present to assist the patient in either getting their shoes on or transferring from the wheelchair. All these human shortcomings qualify the cause of the patient accident as a human error.

The IOM proposed several remedies that would address the errors involved in the accident scene in focus and hence improve patient safety. For one, this error should not be viewed as an individual or attributable to the absentee nurse but rather as an organizational failure owing to the approval of the risky designs. The vital step here is to identify the error (IOM, 1999). Consequently, the facility should aim to learn from the said error, act proactively, and establish measures of reporting any other errors that may occur within the facility. In so doing, it would ensure that all errors are addressed individually and that they all contribute to learning, which would consequently prevent their recurrence (IOM, 1999). The facility should ensure that it sets clear performance standards, complete with enforcement, review, reward, and punitive measures depending on the performance. Consequently, employees will give all their attention to patient care, ensuring that safety is prioritized at all times.


Oh my! I have always known that there are incidences of errors that jeopardize patient safety, but their extent as uncovered in the course of this reading is beyond my estimation and expectations. It is unacceptable that the healthcare system, which is entrusted with improving and safeguarding patients, causes more deaths than the eighth leading cause of death in the United States. Consequently, it is essential that measures are instituted to curb the occurrence of these errors and ensure that whenever they occur, they are not only reported but also used for learning, which would ensure the improvement of healthcare delivery and patient safety.


Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: The National Academies Press.

Institute of Medicine. (2004). The executive summary: Keeping patients safe: Transforming the work environment of nurses. Washington, DC: The National Academies Press.