Risk Management Program Analysis Part One
Patient Safety and Risk Management Program
Description
A risk management plan is the program of choice for the current study because it can serve as a model through which organizations can develop patients’ safety guidelines and risk management plans. The type of risk management plans is a patient safety plan that focuses on matters of patients’ safety and associated risk management. It is necessary for the board of directors of any organization to analyze the plan before disseminating it to the staff of the organization (ECRI Institute, 2010). The patient-safety risk management plan can support the mission and vision of a healthcare facility regarding patient safety and risk management.
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In the organizational setting, managers recommend that the responsible departments or individuals in the organization should be keen to identify events early and report them for immediate action to prevent the potential loss of the organization’s reputation (Bolster & Rourke, 2015). The identified plan also features the aspects of loss control and reduction. In that respect, it is a plan that emphasizes the role of losses on patients’ safety and patients’ outcomes. Risk managers in several healthcare facilities aim at minimizing losses in any part of the system to save resources for emergency …show more content…
It collaborates with other stakeholders in the healthcare system to evaluate healthcare entities and encouraging them to focus on improving healthcare safety (Joint Commission, 2017). Further, the commission ensures that the healthcare services administered to patients are effective in addressing their health concerns and meets the quality standards set by the commission. The standards developed by the commission mainly relate to patient safety, and that is adequate evidence of the commission’s commitment to improving patient safety across healthcare facilities in the country. The standards aim at addressing the safety of medication, transfusions, staff competence, fire safety, security, surgery and anesthesia, seclusion and restraint, and infection control. Sentinel event policy is a famous aspect of the Joint Commission. Implemented in 1996 and revised in 2014, the sentinel policy incorporates patients’ safety and enhances the clarity of the processes of the joint commission (Joint Commission, 2017). Moreover, the joint commission conducts credible and wide-ranging systematic investigations to make changes for reducing the risks and regulating the efficiency of the
middle of paper ... ... Root Cause Analysis in Response to a Sentinel Event. Retrieved on March 2014 from world wide web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdf Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors.
Standards are important aspects of nursing that a nurse must learn and implement every day for the rest of their nursing career. These standards provide for a nurse’s competence in the quality of care they deliver to the public. Standards offer a necessary guidance to nurses everywhere in an effort to ensure that people are treated correctly and ethically. Patients expect nurses to have a general knowledge of the medical realm and to know exactly what it is they –as nurses- are responsible for. Nurses need to have a sense of professionalism that enable the patient to feel safe and secure, knowing that a competent person is caring for him. A lack of professionalism does the opposite, making it impossible for a patient to trust or respect the nurse caring for him. Standards of nursing, if utilized correctly, give the nurse that sense of professionalism the patient is expecting. It insures for the safety of the patient and allows the nurse to provide quality health care that is expected of a medical professional.
It is imperative that Health Care Professionals learn to manage risk. There are many factors to think about including environment, assessment, identification and prioritising when managing risk. Being able to strategically implement preventative measures will help in managing risk. Risk management works hand in hand with all enablers set out by chapelhow.
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
Health is an ever growing and developing sector. Newer diseases raise their head from time to time. These developments put new challenges for mankind. To meet the challenges put forward by the diseases and their outcomes; there is a need for scientific and strategic innovations. These innovative measures empower the healthcare sector to fight the disease and overcome the disease burden. Australian commission on safety and quality in healthcare is also one such innovative step that aims at provision of a universal healthcare service to all across Australia.
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
Safety is focused on reducing the chance of harm to staff and patients. The 2016 National Patient Safety Goals for Hospitals includes criteria such as using two forms of identification when caring for a patient to ensure the right patient is being treated, proper hand washing techniques to prevent nosocomial infections and reporting critical information promptly (Joint Commission, 2015). It is important that nurses follow standards and protocols intending to patients to decrease adverse
The Joint Commission was founded in 1951 with the goal to provided safer and better care to all. Since that day it has become acknowledged as the leader in developing the highest standards for quality and safety in the delivery of health care, and evaluating organization performance (The Joint Commission(a) [TJC], 2014). The Joint Commission continues to investigate ways to better patient care. In 2003 the first set of National Patient Safety Goals (NPSGs) went into effect. This list of goals was designed by a group of nurses, physicians, pharmacists, risk managers, clinical engineers, and other professionals with hands-on experience in addressing patient safety issues in a wide variety of healthcare settings (TJC(b), 2014). The NPSGs were created to address specific areas of concern in patient safety in all health care settings.
Patient safety is a major issue in health care, especially in the public sector. Studies show that as many as 10 patients get harmed daily as they receive care in stroke rehabilitation wards in hospitals in the United States alone. Patient safety refers to mechanisms for preventing patients from getting harmed as they receive health care services in hospitals. The issue of patient safety is usually associated with factors such as medication errors, wrong-site surgery, health care-acquired infections, falls, diagnostic errors, and readmissions. Patient safety can be improved through strategies such as improving communication within hospitals, increasing patient involvement, reporting adverse events, developing protocols and guidelines, proper management of human resources, educating health-care providers on the need for patient protection, and commitment of the leadership to the task. This paper talks about patient safety and how it can be improved in stroke rehabilitation wards of both public and private hospitals.
The standards of the Joint Commission are a foundation for an objective evaluation process the may help healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key for providing safe high quality care services. The Joint Commission’s standards set goal expectations of reasonable, achievable and surveyable performance of an organization. Only new standards that are relative to patient safety or care quality, have positive impact on healthcare outcomes, and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develop these standards.
• Adverse events: An unintentional act that does not accomplish its outcome such as medication errors and adverse drug events or reactions. • Hazardous Condition: It is any set of conditions, which considerably increases the likelihood of a severe physical or mental adverse patient outcome without the disease or situation for which the patient is being treated for. • Sentinel Event: Is a sudden event comprising death or severe physical or mental injury or the risk. It includes any process variation for which a repetition would significantly carry a chance of serious adverse outcome e.g. loss function. • Root Cause Analysis: It comprises of Investigation, Analysis, Coordination and Reporting of incidence or sentinel occurrence which the results are forwarded to Patient Safety Committee and is the reviewed by appropriate entities for further, in-depth evaluation, review and responses for
The National Patient Safety Goals are a key when it comes to patient safety. Implementing safety goals helps reduce the number of medication errors, improves communication between members of the healthcare team and reduces the number of infections patients acquire while under the hospital’s care. In addition, The Joint Commission reviews and publishes these goals each year. Depending on the occurrence of sentinel events, the goals are re-evaluated or revised accordingly. It is important that The Joint Commission reinforce the practice of patient safety goals in that they help improve patient care.
The rate of errors and situations are seen as chances for improvement. A great degree of preventable adversative events and medical faults happen. They cause injury to patients and their loved ones. Events are possibly able to occur in all types of settings. Innovations and strategies have been created to identify hazards to progress patient and staff safety. Nurses are dominant to providing an atmosphere and values of safety. As an outcome, nurses are becoming safety leaders in the healthcare environment(Utrich&Kear,
Longo, D. R., Hewett, J. E., Ge, B., & Schubert, S. (2005). The long road to patient safety: A status report on patient safety systems. JAMA: Journal of the American Medical Association, 294(22), 2858-2865.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).