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Reducing Medical Errors

Michelle Tristani, MS, CCC-SLP

September 15, 2016

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Question

What are some recommendations to reduce medical errors?

Answer

The Institute for Healthcare Improvement has provided recommendations to reduce medical errors and produce a safer medical system and culture.  They suggest that leadership is key; using top down methods for success. Communication is a big factor. Changing the organizational culture and making the “right choice” the easiest thing to do. Respecting human limits and recognizing the issues of stress, fatigue, workload, circadian rhythms, and limits to memory can also help to reduce errors. 

Recognize that multi-disciplinary teams and rounds, or meetings, related to specific patients who have a lot of diagnoses and co-morbidities, can be helpful. Those teams can help ensure that everyone is hearing the same thing at the same time. It is important to implement simple and clear systems and processes and train all staff involved.  Encourage the reporting of errors and encourage a learning environment to help prevent and reduce medical errors.

Other recommendations include:

  • Simplifying - by reducing hand-offs and steps in processes 
  • Standardizing - limiting any unneeded variety in drugs, equipment, supplies, rules, and/or procedures. When there are so many different types of equipment, it can become confusing.
  • Stratifying - avoiding the cookie-cutter mentality of a “one size fits all” approach
  • Improving communication - using standardized vocabulary and feedback. If the Mini-Mental Status Exam is an exam that has universal language, or the Montreal, (MOCA) or the Saint Louis; if one of those uses standard vocabulary that everybody understands, then let's not fix what is not broken, definitely.
  • Supporting time for team communication and collaboration, and encouraging information exchange. 

Michelle Tristani, M.S CCC-SLP, has provided speech pathology services for 24 years across adult and geriatric settings from acute care to skilled nursing to out-patient. Michelle specializes in progressive neurological diagnoses, specifically, Alzheimer’s and related dementias.  She has delivered a wide scope of trainings including, yet not limited to, cognitive disorders, dysphagia in persons with dementia, medical errors and ethics, management of the pulmonary, medically complex and palliative care patient populations. 


michelle tristani

Michelle Tristani, MS, CCC-SLP

Michelle Tristani, M.S CCC-SLP, has provided speech pathology services for 24 years across adult and geriatric settings from acute care to skilled nursing to out-patient. Michelle specializes in progressive neurological diagnoses, specifically, Alzheimer’s and related dementias.  She has delivered a wide scope of trainings including, yet not limited to, cognitive disorders, dysphagia in persons with dementia, medical errors and ethics, management of the pulmonary, medically complex and palliative care patient populations.  Michelle is currently a clinical specialist with Kindred Healthcare, is a speech-language pathologist at St. Elizabeth’s Medical Center in Boston, and is also an Alzheimer’s Association Helpline Counselor.


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