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Patient safety and risk management
Patient safety and risk management
Patient safety and risk management
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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
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.
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...
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
Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.
National Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. S D Pearson, T H Lee, E Lindsey, T Hawkins, E F Cook, and L Goldman. (1994)
Blum,J.,(2011). Improving quality, lowering cost: The role of health care delivery system: U. S Department of health and human services.
Root cause analysis is a tool used by many businesses to determine why an event happened. This process is still rather new to the health care sector. In health care, root cause analysis can be helpful in several ways but there are limitations to its usefulness as well. The process for conducting a root cause analysis is not lengthy in terms of steps; however, it can take time to find all of the mitigating factors involved with the incident. The case study provided is a classic example of when and why a root cause analysis should be used in a health care setting. In addition, the discussion provided within the case study supports the use of root cause analysis in health care.
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).
This study is intended to further understand the impact of health care quality and cost
The form shall be posted on employee bulletin boards and shall be discussed in weekly safety meetings until all employees at the job site have been informed of the incident. Corrective Actions Resulting from Incident Investigations Incident investigations should result in corrective actions, individuals should be assigned responsibilities relative to the corrective actions, and these actions should be tracked to closure. Site Managers are held accountable for closing corrective actions. Corrective actions for safety improvement input are posted at each site and tracked by the COMPANY Safety Manager to ensure timely follow up and completion.
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
The report was based around the notion that the fault of the incident was not that of the employee, but a result of the employer and the groups that are responsible for making and reinforcing the health and safety rules and
Acquiring Information Whilst in the office Mark and I referred to the HSE LAC 22/13 ‘Incident Selection Criteria Guidance’. This is used to determine whether to investigate an accident or not.
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
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