By Debra Sams, BA, AST, CRCST
Everyone makes mistakes, but they can have devastating consequences in healthcare, where they can impact patient and employee safety. This is certainly the case for errors made in a demanding, high-risk environment like the sterile processing department, where positive patient outcomes hinge on safe, high-quality practices free from shortcuts and other process deviations. Fortunately, our ability to use critical thinking, analyze our errors and learn from them presents opportunities to broaden our knowledge and prevent errors from recurring.
Educators can help facilitate learning and error mitigation by applying strategies that center on focused training, and ensuring that the most egregious, high-risk mistakes are prioritized and addressed immediately.
Communication and Clarity are Critical
Effective communication is the first step in addressing any work-related error. The team member (or members) directly involved must be advised of the error, its impact and the expectations moving forward. Open dialogue is necessary to answer questions, clarify the situation, and determine what led to the mistake or confusion with a process.
Next, an assessment should be conducted to determine if the error resulted from a lack of knowledge or inexperience or was a case of poor judgment, such as deliberately rushing or skipping a step to save time. A supervisor may need to show the employee the policy and procedures to ensure the proper processes are understood. During the assessment period, educators should have the employee demonstrate the process that resulted in the error. Direct observation will help reveal training gaps and highlight an employee’s lack of confidence with a process, showing where further training is needed.
From there, it is vital to determine whether training or retraining is necessary for the team member. To determine if the cause of the mistake has anything to do with the training method, educators can review the employee’s previous performance. Are there similar or recurring errors? Has the person received prior training on the task before this mistake? It is possible that the employee did not receive previous training, or that technology has probably changed, and their skills have not been updated. Whatever the case, re-training may involve direct observation, hands-on demonstrations or role-playing. Each technique is beneficial because it involves active participation and engagement of both the trainer and trainee.
Role-playing is an effective training approach because it lets the employee assimilate real-life situations and apply critical thinking to make more informed decisions based on best practices and choose the most appropriate approach for the situation. Direct observation involves watching the employee perform the task. Areas of weakness or strength are identified during this practice. Observing is another effective and convenient technique because the educator can give direct feedback immediately. Hands-on training or simulation is also efficient for reinforcing employee knowledge and building confidence with a process.
Communicating mistakes with the team is essential for ensuring employees understand the problem and know how to prevent another incident. Although it is never appropriate to reveal the name of the individual who made the mistake, sharing details of the error, along with its impact and proper resolution, is helpful. Discussing the error thoughtfully, without pointing a finger, can foster an environment of learning and trust among team members. Employees will feel more empowered, be able to accept responsibility, and see errors as an opportunity for growth and accountability.
When numerous team members make the same mistakes or if an error jeopardizes patient or employee safety, a root cause analysis (RCA) should be considered. RCAs can be time-consuming and may involve a multidisciplinary team to identify reasons and develop solutions for errors; however, they are well worth the effort.
Conclusion
Committing to continual staff development through training and re-education is crucial to minimize errors and deficiencies in the sterile processing department. Re-education fosters a culture of growth, continuous improvement and accountability for sterile processing professionals. By taking a blameless approach and embracing open communication, educators help develop confident and curious technicians who are eager to learn and apply best practices.
Educators should view error resolution as an opportunity to provide valuable information and training that contributes to safe, high-quality outcomes. They must also remember that everyone, including themselves, makes mistakes. The important thing is working to resolve them effectively.
Debra Sams, BA, AST, CRCST, is a columnist for the Healthcare Sterile Processing Association and the sterile processing educator for Cedars-Sinai Medical Center in Los Angeles.
