Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
patient safety and risk management
patient safety and risk management
patient safety and risk management
Don’t take our word for it - see why 10 million students trust us with their essay needs.
Recommended: patient safety and risk management
Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis.
Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root analysis is a systematic approach to collect information that may identify and evaluate hazards and risks (Williams, 2008). The root analysis provides a starting point on areas that may need changing. There are three areas to a root cause analysis of the adverse event which can enable the investigator to; 1) isolate the circumstances that increased the risk of an accident or incident from occurring; 2) determine who or what was involved in the situation; and (3) assess whether the facility might have control over the causes of the event (William, 2008). Using a report outline can help gather information consistency and completeness (Williams, 2008). The outline below evaluates the Samantha Jones adverse event.
1. Policy or Process (system) in Which the Event Occurred:
a. The policy or process did not confirm the correct patient
i. Nurses did not feel that they could voice their opinion about a proper time out
b. Time out was not conducted thoroughly
2. Human Resources (factors and issues)
a. No...
... middle of paper ...
...004). Root cause analysis applied to the investigation of serious untoward incidents in mental health services Retrieved from. http://pb.rcpsych.org/content/28/3/75.
Parker, D. (2008). Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF) Journal of Nursing Management; Mar2009, Vol. 17 Issue 2, p218-222.
Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (2008). The healthcare quality book. (2nd ed.). Chicago, IL: Health Administration Press.
Rooney, J.J. & Vanden Heuvel, L. N. (2004) Root Cause Analysis for Beginners. Retrieved from. https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdf
Williams, L. (2008) The value of a root cause analysis. Long-Term Living: For the Continuing Care Professional, Nov2008, Vol. 57 Is
Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors. Retrieved on March 2014 from world wide web at http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf
A root cause analysis is a mechanism used to determine if procedures prompt sentinel occasions. A sentinel occasion is characterized by Cherry and Jacob as "a startling event that can cause genuine physical or psychologic damage or the danger thereof." (Cherry and Jacob, 2011, p. 444) The goal of a root cause analysis is to distinguish the components which brought on the sentinel occasion and to recognize imperfections in the framework which can be adjusted with a specific end goal to keep a rehash of the occasion later on. A root cause analysis is not used to accuse people, and is not relevant when the occasion is deliberate, or brought on by carelessness or a criminal intent. Root cause analysis concentrates on disappointments in the framework
The patient safety program in hospital setting is intended to reduce medical errors and hazardous conditions by assuring an environment that inspires error identification, reporting and prevention through education, system enhancement for any adverse occasions such that information about sentinel events that frequently occurs in health care are built in the system progressively for risk reduction. Through education component, proper and effective orientation and training that emphasizes clinical and non-clinical aspects of patient safety, including an inte...
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
There was inappropriate staffing in the Emergency Room which was a factor in the event. There was one registered nurse (RN) and one licensed practical nurse (LPN) on duty at the time of the incident. Additional staff was available and not called in. The Emergency Nurses Association holds the position there should be two registered nurses whose responsibility is to prov...
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.
Blum,J.,(2011). Improving quality, lowering cost: The role of health care delivery system: U. S Department of health and human services.
The World Health Organization outlines 6 areas of quality that help shape our definition of what makes quality care. Those areas are; (1) Effective: using evidence bases practice to improve health outcomes based on needs of individuals and communities. (2) Efficient: healthcare that maximizes resources and minimizes waste. (3) Accessible: timely care that is provided in a setting where the skills and resources are appropriate for the medical need and is geographically reasonable. (4) Acceptable/Patient-Centered: healthcare that considers individual needs, preferences, and culture. (5) Equitable: healthcare quality that does not vary because of race, gender, ethnicity, geographical location, or socioeconomically status. (6) Safe: healthcare that minimizes harm and risks to patients. (Bengoa, 2006)
This study is intended to further understand the impact of health care quality and cost
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,
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).
Determining all the possible factors that are involved in an accident can help an investigator determine all the probable causes contributing to the accident. This can also help to determine weather or not the probable cause could have been prevented. All accidents usually have multiple contributing cause and factors which lead to a series of events causing the accident. Three of the most common cause and factors involved in a crash are the aircraft itself, the environment, or personnel (NTSB, 2010). Personnel factors are the leading cause of aircraft accidents.
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
William, R. (2009, August). Improving quality and value in the u.s. health care system. Retrieved from http://www.brookings.edu/research/reports/2009/08/21-bpc-qualityreport
Incident/accident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also to improve workplace morale and increase productivity, by demonstrating an employer’s commitment to a safe and healthful workplace. Incident/accident investigations are often conducted by a supervisor but to be most