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Errors in healthcare
Reflection on patient safety
Errors in healthcare
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The term “safety comes first” or more simply put, “safety first,” is a message that patients not only want to hear, but also want to know is the focus of the professionals that are caring for them; in particular, when they are under anesthesia and have limited or no ability to speak up or lookout for themselves. The National Patient Safety Agency (NPSA) has implemented two initiatives; Rocognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients (NPSA, 2007) and How to Guide: Five Steps to Safer Surgery (NPSA, 2010). Understanding that human beings make up the healthcare professional workforce, it is evident that tools and checklist can and will only be as good as the how people utilize and follow them. Thus, these initiatives “have been developed with consideration of human factors” (Beaumont & Russell, 2012). I know firsthand, that if my healthcare team would have followed these standards, I would have avoided torture, fear, and long term side effects from a routine hysterectomy procedure.
Initiatives in Detail
Rocognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients (NPSA, 2007) stemmed from the investigation as to why patient deterioration was not being acted on or recognized by healthcare workers. The exploration identified a number of failures centered on lack of proper observation and recordings of observations, and lack of proper communication between hospital staff members. The study uncovered concerns from staff members not observing patients at night, to undertrained staff left to interpret vital signs and perform work outside of their level of expertise. It also showed a pattern of little to no communication between medical colleagues ...
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...ntroduction of these two initiatives, there has been documented evidence of reduced incidences. Unfortunately, the human factor is still and will always be an issue. Success in clinical environments will only come if these tools are implemented and used properly, not just as “a tick box exercise” (Featherstone, et al., 2010).
Works Cited
Beaumont, K., & Russell, J. (2012). Standardising for reliability: the contribution of tools and checklists. Nursing Standard, 26(34), 35-39.
National Health Service (NHS) England. (n.d.). Five Steps to Safer Surgery Film [Video File]. Retrieved from http://www.nrls.npsa.nhs.uk/patient-safety-videos/five-steps-to-safer-surgery/
Featherstone, P., Prytherch, D., Schmidt, P., Smith, G. (2010). ViEWS: towards a national early warning score for detecting adult inpatient deterioration. Resuscitation, 81(8), 932-937.
Potter, J. E., White, K., Hopkins, K., Amastae, J., & Grossman, D. (2010). Clinic Versus Over-
Health Improvement Scotland coordinated the Scottish Patient Safety Programme created to improve the safety of patients across Scotland (NHS Scotland, 2010a). Four groups were created to manage patient safety, one of which was established to supervise care within an acute adult setting (NHS Scotland, 2010a). During my practice learning experience a male patient was brought into the accident and emergency department following a serious assault, he had suffered severe lacerations to his head, face and hands. Prior to arriving, ambulance staff did not call to warn nursing and medical staff. As a result, the team were unprepared and the patient was brought into the wrong area within the department. The patient should have gone straight into the resuscitation area where the appropriate equipment is available, in case of patient deterioration (Brooker and Nicol, 2011).
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.
O’Daniel, M., & A.H., R. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville: Agency for Healthcare Research and Quality. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK2637/
This week readings bring us overview of the issues we face in today’s healthcare such as “safe, effective, patient-centered, timely, efficient, and equitable” care (IOM, 2001, p 3). Safety and quality of care are the major factors which I think must be address to assure the best possible patients’ outcomes and to build culture of safety.
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.
Thus, it is imperative that evidence-based practice is conducted to provide the best current, valid and reliable evidence in an aim to close the gap between non-conformity and coincide with the professional obligation of providing the patient with the best possible care (Liamputtong, 2013).... ... middle of paper ... ... Patient safety and quality of care. Rockville, MD: Agency For Healthcare Research And Quality, U.S. Dept. of Health.
The overall goal for the Quality and Safety Education for Nurses (QSEN) plan is to meet the challenge of educating and preparing future nurses to have the knowledge, skills and attitudes that are essential to frequently progress the quality and safety of the healthcare systems in the continuous improvement of safe practice (QSEN, 2014).Safety reduces the possibility of injury to patients and nurses. It is achieved through system efficiency and individual work performance. Organizations determine which technologies have an effective protocol with efficient practices to support quality and safety care. Guidelines are followed to reduce potential risks of harm to nurses or others. Appropriate policies
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
Respiratory assessment is a significant aspect of nursing practice. According to the National Institute for Health and Care Excellence, respiratory rate is the best indicator of an ill patient and it is the first observation that will demonstrate a problem or deterioration in condition (Philip, Richardson, & Cohen, 2013). When a respiratory assessment performed effectively on a patient, it can result in upholding patient’s comfort and independence in progress of symptom management. Studies have acknowledged that in spite of the importance of the respiratory rate (RR) it is documented rarely than the other vital signs in the hospital settings (Parkes, 2011). This essay will highlight the importance of respiratory assessment and discuss why nurses
The following essay is a reflective paper on an event that I encountered as a student nurse during my first clinical placement in my first year of study. The event took place in a long term facility. This reflection is about the patient whom I will call Mrs. D. to protect her confidentiality. Throughout this essay I will be using LEARN model of reflection. I have decided to reflect on the event described in this essay since I believe that it highlights the need for nurses to have effective vital signs ‘assessment skills especially when treating older patients with complex medical diagnoses.
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 reflection of vital signs will go into discussion about the strengths and weaknesses of each vital sign and the importance of each of them. Vital signs should be assessed many different times such as on admission to a health care facility, before and after something substantial has happened to the patient such as surgery and so forth (ref inter). I learned to assess blood pressure (BP), pulse (P), temperature (T) and respiration (R) and I will reflect and discuss which aspects were more difficult and ways to improve on them. While pulse, respiration and temperature were fairly easy to become skilled at, it was blood pressure which was a bit more difficult to understand.
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
This incidence approximately occurs at a rate of one in 30,000 to less than one in 100,000 surgeries. The actual incidence might be even higher due to a reporting bias. The World Health Organization (WHO) created the safe surgery checklist in the year 2008. The aim of the safe surgery checklist was to diminish mistakes in patient care and adverse events. The WHO’s patient safety checklist has made recommendations to improve teamwork and communication (Thurnherr et al., 2017). The Universal Protocol also highlights the use of timeout before all procedures related to surgery and any invasive procedures. The concept of the surgical timeout is to set aside a planned time meeting in order to review crucial aspects of the procedure with all involved personnel. It helps in developing better communication in the operating room and lowers the risk of wrong site patient surgery (PSNet,