When Errors Cause Tragic Harm

In June 2023, a coroner’s report investigating the death of an older person in a residential aged care facility was shared in patient safety forums and clinical alert newsletters around Australia to highlight the critical and tragic outcomes associated with medication errors and clinical risks. It states on the Aged Care Quality and Safety Commission’s Clinical Alerts web page that ‘the error that occurred was a duplication of two [aged care] resident profiles’ in an electronic system, which caused a resident to be given someone else’s prescribed medication. The Clinical Alerts site added the caution that ‘the same or similar names are always a red flag when checking, prescribing and administering medications’.

So, how was this missed, and could clinical education have a role here? Clinical educators tie together person-centred care and clinical decision-making processes with evidence-based practice and a dynamic view of safety in action. Their role is integral to strengthening systems of care through support and clinical safety leadership.

This article will take a look at how clinical education plays an important part in mitigating risk by outlining the positive influence educators bring to practice. They are perfectly placed to address knowledge gaps in care teams by combining learning with innovation.

What is a Clinical Risk?

A clinical risk is where a process, action or operational factor related to the provision of care has the potential for negative consequences for safety (Australian Commission on Safety and Quality in Health Care, 2024)). If the risk is realised, an adverse event is caused by either intentional or unintentional actions or system problems. An error or adverse event in a complex environment like aged care is usually the outcome of a series of issues and conditions that create a pathway of connected consequences. The Swiss Cheese model is a good illustration of what occurs when a number of risk mitigations or controls miss the mark or are insufficient, creating multiple fail points in sequence and causing the ‘holes to line up’.

While not all risks can be removed or controlled fully, in the Clinical Alert mentioned above, harm reached the older person because of systemic failures before the medication was administered, which led to a nurse giving medication that was exactly what was stated on the order but to the wrong person, without visibility of the duplication. The coroner noted that the person’s death was due to significant failings, which did not provide adequate checks and balances when moving from a paper medication chart to an electronic medication management system.

The coroner, in this case, made several recommendations relating to medication safety protocols and current best practices to mitigate some of the risks in medication management. These include:

1. Role responsibility: General practitioners (GPs) and other prescribers such as Nurse Practitioners have overarching responsibility for authorising medication charts, whether they are electronic or handwritten.
2. Policies and protocols: These are enacted to outline the minimum safety checks, such as requiring two people to independently check medication records when changes are made in order to avoid confirmation bias errors and transcribing errors.
3. Advisory and review: It is recommended that aged care services screen and monitor risks relating to medication management, such as via medication audits, and review errors and improvements in an aligned committee or advisory group.
4. Resident and family insights: To support a safety-focused culture, staff, residents and involved family members should be able to raise risks or concerns about care.
5. Medication safety: Support all staff involved in medication administration to ensure the 6 rights of medication are carried out every time.

A Clear Need for Improved Training and Education

The aged care service involved in the duplication error committed to implementing reforms, including regular audits, a policy to check new medication packs against medication charts and further training for staff on medication administration. Although there needed to be more detail offered on the exact type of clinical education planned, teaching staff to proficiently and safely use electronic medication systems is a core activity in the implementation phase of a new system. Training needs to provide opportunities to work through simulated exercises to familiarise staff with the new electronic workflows and provide support and dedicated time to practise and consolidate the new skills. Clinical education enhances learning and mitigates risk in this context by bridging technical skills together with practice experience and safety standards in a controlled ‘safe to fail’, simulated environment (Lame & Dixon-Woods 2020).

Education Enhances Staff Knowledge and Skills

In the coroner’s report referred to above, clinical education and training were mentioned superficially. However, clinical education structured well, delivered successfully and evaluated for impact provides a scaffold of support for all aspects of clinical risk management. Clinical educators help staff to identify risks and take action to prevent those potential error ‘holes’ lining up. For example, in an initiative to prevent and manage violence and aggression, clinical education designed to support skill development demonstrated an increased use of verbal de-escalation techniques and fewer incidents in their workplace (Adams et al. 2017). After the education, staff knowledge increased significantly, and their confidence in managing incidents and their capability to identify risks and take preventative action was enhanced.

Closing Gaps in Knowledge and Situational Awareness

The introduction of new systems or processes heightens the clinical risk for a number of important reasons: a change in practice is accompanied by unfamiliarity and increased cognitive load during the initial stages of the implementation, and also introduces new and different kinds of error potential, such as an increase in duplication errors (Naamneh & Bodas 2024). It is about more than just following new steps correctly or signing off on a learning module - it has been estimated that up to 80% of medical errors result from a breakdown in non-technical skills. Clinical educators mitigate clinical risks by coaching staff in the handling and processing of information about what is occurring around them in order to anticipate and manage high-risk situations (Walshe et al. 2021). By helping staff to comprehend, communicate and cooperate effectively, clinical educators teach awareness of the human and environmental factors that impact safety, and they reinforce the use of evidence-based tools designed to standardise safety practices (Gluyas & Harris 2016).

Coaching Staff to Change

Clinical educators act as change agents and have a significant positive effect on organisational learning culture, guiding staff to the target state of a new process by clarifying the ‘why’ of the change. They engage with staff to realise organisational outcomes and standards, not just improvement at the individual level (Grealish et al. 2014). Addressing the sociocultural aspects of change in a care setting is often more important than teaching a new workflow or process because staff who can voice concerns and questions comfortably in a learning situation are more likely to speak up about the risks and issues that they see (Creadon-Shanks et al. 2020).

Challenges in Mitigating Risk

Further analysis of medication errors identified from aged care complaints highlights how prevalent medication errors are due to the complex and contingent nature of medication management in this challenging setting. A study looking into the themes of medication-related deaths in Australian residential aged-care facilities found that deaths involving high-risk medications occurred primarily at the stages of medication administration and during the phase of monitoring for effects (Jokanovic et al. 2019). There were very few specific recommendations made by coroners, and in turn, there was no way of knowing whether the recommendations were successfully and sustainably implemented (Jokanovic et al. 2019). Clinical educators should be included in incident reviews so their expertise can inform any training interventions or alternative actions to prevent the adverse event from reoccurring.

While further research is needed to understand the benefits of specific teaching strategies or activities, educators can draw from a variety of learning approaches and modalities to enhance clinical safety and respond to risk (McCloskey et al. 2020). By utilising standardised care processes and facilitating access to evidence-based clinical resources for key areas of clinical risk, clinical education can embed safety-critical practice into all levels of learning. Educators are best placed to introduce opportunities for the development of problem-solving, research, reflection and critical thinking skills when applied in real-world contexts (Mthiyane & Habedie 2018).

Clinical Educators Are Safety Champions!

Healthcare education is grappling with the changes to how and where care is provided and even how training is conceptualised, with a new reliance on software applications, data and information sharing. Technologies such as electronic medication management systems undoubtedly cause disruption and challenges related to safety, risk and ways of working but bring safety benefits with the ability to share information in real-time and build in clinical decision support to help guide assessments and care interventions that are personalised and effective. However, the role of technology in supporting quality and safety as well as enhancing educational efforts (e.g. e-learning platforms, virtual reality simulations) is not always clear, so clinical educators need an advanced level of digital capability and an understanding of the limitations and benefits of technology to mitigate risk.

Clinical educators need to be super-users of any systems and tools utilised in aged care settings to be able to assess the level of competence and proficiency of others. Having an expert, holistic understanding of systems of care, digital or not, or a hybrid combination, supports the design and delivery of education programs that reliably make a difference. In addition, clinical educators need to be aware of the pitfalls of digital versus paper and the transitions between the two, as highlighted by transcribing errors. They can then help their colleagues use digital tools safely, using implementation processes backed by research.

Conclusion

Clinical education is a vital component in mitigating clinical risks in key areas of healthcare, such as recognising and responding to deterioration, communicating and handover, and safe medication management. While barriers and constraints exist in terms of role scope, time availability and resource constraints, access to clinical education, not just basic compliance-based training (e.g mandatory training) is critical. Safe, evidence-based practice, underpinned with high-quality education is correlated with increased safety, positive outcomes and a better experience of care for recipients (Mthiyane & Habedi 2018).

As translators of theory into practice, clinical educators have expertise in applying risk assessment and clinical governance best practices to the delivery of care. A training lens brings an understanding of how and which skills or roles work together to promote best-practice care for those in aged care with complex needs and health conditions. Innovative educational approaches further enhance aged care safety and healthcare quality by grounding care staff in what better care safety first looks like while driving improvements and change.

A new generation of learners requires that clinical educators innovate safely and meet the training needs of their organisation to prepare staff for working in an increasingly complex environment, increase system resilience and strengthen the actions and interventions required to prevent harm. Digital transformation is an important opportunity for clinical educators to demonstrate the impact of their roles in mitigating risk and promoting safety in aged care.

References

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