...There are eight things that I learned when reviewing the patient safety goals of 2008. The first important lesson that I learned was about improving the accuracy of patient identification. It is always important to use at least two patient identifiers when providing care, treatment or services. No matter how silly it may seem, having the correct patient is tantamount. The next patient safety goal is regarding how to improve the effectiveness of communication among caregivers. I found it to be critical to understand the proper way in which to transfer information from one person to the next. Having a standardized system for information sharing is a key part of patient safety. The third principle that I learned was in regard to improved safety of using medications. It is crucial to label medication containers, as well making an annual list of drugs that look alike or sound alike. Making sure that drugs do not get confused or mixed up is definitely going to keep patients more safe. Another concern regarding patient safety is the concept of reducing the risk of health care-associated infections. This can be achieved by maintaining a high level of hand hygiene and by closely monitoring unexpected deaths or major loss of function associated with health acquired infections. The subject of accurately and completely reconciling medications across the continuum of care is pertinent to keeping patients safe. In order to accomplish this, a process needs to be in place...
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...necessary to achieve success in preventing wrong site surgery include the board of trustees, medical executive committee, directors, senior management, nurses, physicians, other healthcare staff and ancillary staff. The senior management members are the role models for the hospital staff. Similarly, all leadership roles within the healthcare organization, formal and informal, must possess and exhibit the identical vision of zero patient harm (Chassin and Loeb, 2013). Additionally, the Risk Manager and Quality Department staff performs an important role in implementing, maintaining, assessing, and auditing quality and patient safety initiatives. In this case analysis, the key roles that influenced the outcome of a wrong-site surgery event include the emergency department triage staff, emergency department staff (physician, nurse, medical assistant or technician, and/or emergency medical technician), holding area nurse, anesthesiologist, surgeons, and operating room staff. There were plenty of opportunities to stop the sentinel event from occurring. The patient went from one caregiver to the next without a proper verification process. The senior management team with the support of the board of trustees and medical executive committee must hold all healthcare staff employees responsible for their part in risk reduction (Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare, 2014)....
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...“One could not always put safety up front as the prime goal. Do that, and who would ever achieve anything of note?” Jack McDevitt Introduction The word “safety” is mentioned 46 times in the current guidelines: Word Frequency Rank Adjusted Rank trial 437 1 1 subject 256 2 2 sponsor 210 3 3 clinical 207 4 4 investigator 155 5 5 product 149 6 6 data 120 7 7 investigational 113 9 9 protocol 103 11 10 regulatory 103 12 11 monitor 97 14 12 IRB/IEC 88 19 14 inform 73 26 15 consent 68 30 16 procedure 61 34 18 investigator/institution 58 35 19 record 58 36 20 appropriate 52 37 21 requirement 50 38 22 review 49 39 23 safety 46 41 24 quality 43 44 25 adverse 38 48 27 authority 35 50 29 Interestingly, as can be seen in the above abbreviated table,...
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...Patient Safety in a Home Care setting 1 Kimberly Casimier Chamberlain College of Nursing Instructor: Pamela Morgan September 27,2014 Patient Safety in a Home Care setting 2 Introduction Thousands of deaths are caused and could have been prevented if patient safety measures would have been taken. It is very important improve patient safety compliance to prevent things like surgeries being done on the wrong site, medication errors, health care acquired infections, falls, and diagnostic errors. Patient safety not only takes place in the hospital, doctors office, and rehab/nursing home facilities, but it also takes place in the home care setting. The Speak Up home care brochure is geared to inform that patient on what to speak up about in the home care setting and if the patient speaks up and the nurse of healthcare worker complies, more errors can be prevented. The home care brochure really gives that patient many options of questions to ask the nurse or healthcare working during their home care. It empowers that patient and hopefully helps them know what they are entitled to as a patient as far as home care, questions they should ask if they are concerned and for information purposes, and I hopefully helps the patient to not be...
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...Abstract Patient safety and Medical errors are one of the major concerns of healthcare industry. Our group decided to throw more light on the present situation of this issue. In this paper we have given a clear picture about the types of errors, how these errors occur and towards the end we have discussed on how to prevent these errors. The implementation of the actions to prevent errors discussed in our paper will help in improving and reducing them. In doing so, we can be leaders in an effort to provide the best care possible to all Americans. We have also discussed about the importance of patient safety. Reducing errors and improving how we respond to error is but a subset of the all-important issue of quality of care. TABLE OF CONTENTS Introduction ……………………………………………………………………………... 5 Regulatory Authority……………………………………………………………………. 5 Patient safety ……………………………………………………………………………. 6 Medical Errors ………………………………………………………………………….. 7 Why medical errors occur? .............................................................................................. 8 When errors are not reported ………………………………………………………….. 8 Types of Medical Errors ………………………………………………………………… 9 Sentinel Events ……………………………………………………………………….. 9 Diagnosis or evaluation ………………………………………………………………. 9 Medical decision-making …………………………………………………………… 10 Treatment and medication …………………………………….…………………..… 10 Dispensing ……………………………………………………………………………11 Procedural complications...
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...The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. Patient identification is a big deal in healthcare because you want to make sure every patient is getting the correct care. A person with type A blood cannot receive blood that is type B, and that is why identifying every person is important. One way we can decrease the chances of misidentifying a patient is to ask the patient to state their name. This is a productive way to identify a patient, but if you are somewhere like a long-term care facility some of the residents do switch beds and don't remember their name. Another way to identify a patient is to use their date of birth. In hospitals...
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...Nursing Contributions in the Promotion of Safety Western Governor’s University Interdisciplinary teams are formed in most hospital settings. The individuals involved in the total care of a patient come together to discuss, plan, and implement patient care or care based improvements in protocol. Discussions on proposed topics reviewed by the team present an opportunity to weigh out all options and develop the best way to resolve issues with which they are faced. These teams give nurses the opportunity to be actively involved in determining the path of care of their patients. When a nurse serves on the team, they can exhibit leadership qualities without serving in the capacity of an official role. Often the role of the nurse is overlooked by other members of the team. The role of the nurse is to serve as an advocate for their patient and to work in their best interest toward their full recovery and well-being. This can be fulfilled by displaying certain characteristics. Examples include embracing effective teamwork skills and communication and also promoting safety during planning. Effective teamwork and communication helps a nurse to display a sense of leadership and confidence in her own abilities and judgments. According to the Institute for Healthcare Improvement, possessing these qualities will “help groups navigate competing priorities” (PS-103). Utilizing these qualities will allow groups to work in an environment of togetherness and success...
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... as the organization “reinvents itself.” (Johnson, 2009) In the healthcare industry, things are changing every day. New technology, medication, and the way we deal with patients changes on a daily basis. Change is necessary because there are people behind the scenes always finding new ways to better improve the quality of care we give to our patients as well as creating new technology to help assist with the way we treat our patients. Adding and taking away from departments are changing as well. With change we may want to be uninterested with it, supportive of it, to be a participate in it, or unreceptive about it. Whether the case may be, change has increased and will continue to happen whether we like it or not. Throughout this paper I will discuss two healthcare organizations that have experienced change. “Effective change has been characterized as unfreezing old behaviors, introducing new ones, and refreezing them.” (Al-Abir, 2007) Change can be random, rare, occasional, or continuous. Change that are predictable allow preparation time, whereas change that is unpredictable may be difficult for everyone to respond effectively too. Since in healthcare changes happen so fast, they are more than likely predicable. Even though change is recognized, the employees what to be able to understand why change is occurring and how it will affect them in the present as well as in the future. Another key element to guarantee a successful change is to establish a vision that...
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...Deysi Serrano Outline: Patient Safety in Hospitals Chamberlain College of Nursing Outline: Patient Safety and Medical Errors General Purpose: To inform nurses and the general public about programs and policies in place to further decline the rates in medial errors and keep patients safe. Specific Purpose: To provide examples of why implementing proper procedures and having an open communication within the staff can prevent minor medical incidents and potential fatal medical accidents from happening. I. Introduction A. Attention Getter: Present the story of Josie King, a two-year-old girl who died because of a medical error at a renowned hospital. B. Thesis Statement: Extensive research has shown that training programs for health care workers, policies and proven protocols and communication result in an overall decrease in medical error rates. Because implementation of protocols and standardized patient safety procedures have been shown to be effective, there is good reason to expect that by continuing these medical practices, the risk of unwanted medical errors and patient harm will be significantly reduced. II. Body A. Main Point # 1: To express how medical staff and nurses in particular are the voice of concern and advocates for patients who should express open communication with both the families and doctors. 1a. Explain how break down in communication affects the quality in patient care. 2a. Describe some of the implementations hospitals...
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...Patient Safety Workshop Learning From Error PATIENT SAFETY WORKSHOP LEARNING FROM ERROR WHO Library Cataloguing-in-Publication Data Patient safety workshop: learning from error. Includes CD-ROM 1.Patient care - standards. 2.Medical errors - standards. 3.Patient rights. 4.Health facilities - standards. 5.Health Management and Planning. I.World Health Organization. ISBN 978 92 4 159902 3 (NLM Classification: WX 167) This publication is a reprint of material originally distributed as WHO/IER/PSP/2008.09. © World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies...
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...the healthcare field there are several risks whether it involves the patient directly or the staff of the medical facility, but it is essential to manage these risks as much as possible to ensure a safe working environment that renders quality health care and services. Healthcare risk management is defined as the way in which a healthcare organization identifies, manages, mitigates and responds to risks (Sheahan, 2012). With all things taken into consideration this management of risks is compulsory to assist in not only the reduction, but also the prevention of risks that have the potential to cause catastrophic results. Sources of Information Used by Risk Managers Risks managers are able to identify potential risks from a variety of sources such as the assessing the working environment itself, the staff, and also the patients. These sources provide valuable information that enable risks managers to make decisions that affect the organization structurally and financially. When assessing the overall environment there may by changes that need to be made to ensure the safety of the patients that will cause the medical facility to spend more money such as adding additional wheelchair ramps, ordering more wheelchairs, or ordering more supplies to ensure that the patients receive adequate care. The main priority in the area of healthcare risk management should be patient safety (Melone, 2012). Proper review of patient complaints and other mishaps would be beneficial to the risk manager...
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...1. Describe one risk to patient safety that you identified and the interventions taken to ensure patient safety. One risk to safety I identified in my patient was a risk of falls. I had a patient that was very unstable on his feet and was also hooked up to an IV infusion pump. Not only was him being unstable on his feet an issue but also him pulling out the IV that was in his arm. I made sure that a bed and chair alarm was placed in this patient’s room. I also educated him on why it is important to use to call light to ask for assistance when getting out of bed. Core Competency: Caring 2. Describe one situation where you utilized advocacy resources appropriately (e.g., social worker, chain of command, interpreter) During this clinical rotation, I was able to advocate for my patient through the chain of command. I had a patient...
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...Nurse safety have variety of measures which include the organization and safe working environment. Safety measures of nurses rely on how nurses will act toward each other and how they will keep their equipment safe and clean. Nurse safety is important for they’re the ones that holding the lives of each individual patients. It’s important for nurses to first look for their own safety. Without the safety of an individual nurse, the safety of colleagues won’t be able to present. There are things that might happen if one individual nurse don’t protect himself or herself. There are incident that happen that nurses don’t expect but it did happen unexpectedly. The issue of nurses safety is pervasive and includes all settings where nurses practice, not only acute care setting but in the community and home. In order for nurses to practice caring or protecting themselves, they should start off by practicing in the environment and at home, it will be easier for them to protect themselves when in the hospital. The skills and knowledge will gain while practicing at home and in the environment. Sometimes the nurses forgot to look for the complex and dangerous threats that facing them in the working environment. Work place violence, define as the behavior involving physical force intended to hurt, damage, or kill someone or something in the workplace. Work place violence is one major threat that is facing the nurse’s safety in the environment. Nurses might get into trouble if they do not prevent...
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...nursing-sensitive outcome indicators that focus plans/programs to increase quality and safety in patient care. They gauge aspects of direct patient care related to quality of nursing care by reflecting on structure, process and outcomes of nursing care. Structure in regard to staffing and the skill, education and certification of staff; process in regards to measuring aspects of nursing care related to assessment, intervention and RN job satisfaction, and outcomes by improving the rates of specifics in relation to patient outcomes such as in this particular case preventing hospital acquired pressure ulcers, improving patient satisfaction and restraint prevalence. Nursing Sensitive indicators are only specific to nursing and in 1998, ANA developed a National Data base of nursing quality indicators (NDNQI) so they could continue to collect and build on data from studies to expand nursing knowledge related to factors that influence the quality of nursing care. Why is this important? The nursing profession has the responsibility to measure, evaluate and continually improve practice. NDNQI identify where and how the staff is needed and show the need to increase staff in particular areas of nursing care that need improvement. The NDNQI mission is to help the RN in patient safety and quality improvements by providing research based national and comparative data on nursing care in relation to patient outcomes. In this particular case, if the nurse was educated and had an understanding...
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... include all levels of the organization who are knowledgeable about the process that was involved in the incident. For this RCA team members should include the LPN, RN, emergency department physician, emergency department manager. A member of the risk management and or the quality improvement team should be on the team. In many RCA it is also valuable to have a patient on the team. Once this team is formed, members should agree to fill roles on the team. These roles include team leader, advisor, recorder and team members. Once these roles are established the team should identify what happened. Team members should collect information about the event. In collecting the information, it is important to conduct interviews and review medical records. The team should describe the facts of the sentinel event. The team should consider all causative factors, hazards and errors. In this scenario, several errors and hazards are present. Errors in this scenario were that the nurse failed to monitor the patient according to the hospital’s sedation policy, an alarm was ignored and a patient was given multiple doses of a medication without allowing proper time in between doses. Some hazards in this scenario include the high census and low staffing in the emergency...
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