How might acknowledging a medical error promote patient safety?

In this particular case, a system-based approach to care might have anticipated and prevented this error through the following steps:

• Create specific written instructions for office procedures
• Have the written procedures handy and easily available for staff to reference, if needed, before performing the task
• Make sure during new staff orientation that personnel are trained and documented as proficient in each procedure
• Have regular updates or ”recertification,” particularly for procedures that are done infrequently
• A well-informed patient is often the first protection against mishaps. A patient education sheet given to the patient when the TST test was administered—describing the test, how it is interpreted, and implications of a “positive” test result—may have alerted the patient in the first place that her test had been misread
• Create documentation forms that have built in “decision support”—for instance, instead of having a blank that says: “TST_____,” the form instead could describe: “TST: date applied, date read, mm of induration measured in 2 dimensions.”