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The World Health Organization brought patient safety to the fore in the 1990s, when medical reports indicated that one out of every ten patients around the world was impacted by medical errors (WHO, 2011) . These errors committed by the medical practitioners and health care givers resulted in adverse effects on the patients' health and even worse, caused their death in many occasions. A report released in 1999 titled, "To Err is Human: Building a safer health system" by the institute of medicine (IOM), helped raise the profile on the preventable medical errors.
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The IOM raised the call for the establishing of a Center for Patient Safety and the in-depth reporting of the adverse events in the medical field. Efforts were made in bringing this situation to the attention of the health care regulators, the professional societies and the purchasers of health care, and further provided information for the development of safety programs in the health care organizations (IOM, 2004). It was against this background that I attended this event on patient safety. The lessons I learnt really touched me, especially the fact that, in most cases, the patients suffer needlessly as a result of a human error not of their making (IOM, 2000).
We learnt that all points along the process of providing healthcare do possess some form of inhernt unsafety and harm to the patient (WHO, 2011), at times this may be unpredictable. These medical health care errors were defined as preventable and avoidable adverse effects of care, in spite of whether the error is evident and harmful to the patient or not. It was a shock to learn deaths induced by these errors are thought to have averaged between 400,000 to 1.2 million, in the period between 1996 to 2006, in reports by the IOM. The various reasons attributed to these errors were given. These were in the categories of human factors, failures in the health care and systems medical complications.
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Variations that exist in the training and experience of the medical practitioners with some care providers being incompetent leading to lapses or slips and poor judgment are the most common (Vincent, 2010). Human factors also included the fatigue, burnout and emotional state of the health care providers, together with the diversity of patients they had to attend to. Having complicated technologies in some medical operations requiring administration of powerful drugs were conditions for errors, compounded in the case of incompetence or poor judgment by the health care provider. The system of health care has loop holes that further exacerbate the occurrence of these errors. The unclear lines in the chains of authority from the physiciians, nurses and to other healthcare providers together with poor communication was cited as being among the main challenge (Vincent, 2010). Infrastructure failure and their design, over dependence on automated systems and lack of efficient systems in information sharing were given as other complications. The increase in the patient to nurse ratio is one factor in the system that has far reaching implications in regard to this matter. Failure to acknowledge the severity and prevalence of the problem among the practitioners only raises the level of the challenge.
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The adverse events in medical areas as result of these errors may occur from problems in practice, procedures, products or the health care systems in place. I learnt that improvements in patient safety demand a concerted effort within the system, involving a diverse range of actions geared towards improving performance. The fact that there is some degree of inherent harm and un-safety at every point along the medical process, made me realize the need to be diligent in my practice. What I learnt has become the motivation to be a better physician and always perform at my best level. Always wanting to help the suffering patients has been my goal and I would not want negligence on my part or from a member of my medical team to result in further harm to the patient.
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