A medical error is a preventable adverse effect of care that occur in 8-12% of all hospitalizations. These errors contribute to 210,000 deaths due to preventable harm and an annual cost of $17.1 billion dollars from excess hospital costs and lost productivity from missed work. Examples of preventable errors include technical errors, diagnosis, failure to prevent injury, and errors in the use of a drug. Errors are costly in terms of loss of trust and diminished satisfaction in the healthcare system by patients, as well as loss of morale and frustration by the healthcare professional. There are numerous factors that contribute to preventable errors, including new guidelines for patient care generated from clinical research each year, or a lack of well-integrated and comprehensive continuing education system.
Competency assessment and education recommendations utilizing decision matrix tool
A matrix was developed to be used, to determine a level of risk and identify appropriate education and/or competency evaluation methods for key skills, tasks, or procedures in the healthcare profession. This decision matrix utilizes criteria such as: complexity of process; potential for harm to patient; evidence of benefit to patient outcome; staff practice change; institutional frequency; unit frequency; and anticipated resources needed to determine a risk category. The matrix includes recommended means and methods for evaluation of competency as well as documentation of competency achievement. This allows for standardized identification of skills, tasks, and procedures that require competency evaluation, means and methods to evaluate competency, and documenting competency achievement. It will serve to standardize best practices to be used for patient care across a health system.
- Competency evaluation
- Documentation of competency achievement
- Establish competency standards across a health system
- Identification of high-risk skills or procedures