Outline
I. Background
II. Literature Review
III. Nursing Implications
IV. Strategies to Address Issue
V. Conclusion
Background
A culture of safety requires the commitment of leadership to positively impact outcomes. Recent emphasis on the new CMS guidelines and third party reimbursement initiatives associated with patient outcomes, has grabbed the attention of leadership at all healthcare organizations. Additionally, our system wide organization’s employee culture of safety survey has shown that communication and teamwork are areas were improvements are needed. Years of research on communication and teamwork in highly reliable organizations support a correlation with safety. (XX) One of the most important and highly touted Joint Commission, National Patient Safety Goals is to improve communication across the healthcare continuum. (JC .com) Additionally, the organization’s patient occurrences were reviewed through root cause analysis and the source is often linked to a failure to effectively communicate and role confusion. Well defined roles within the team model can help improve communication, including mitigating variables such as distractions, individual emphasis on the wrong information, and a breakdown in communication. (XXX) Implementation of a formal teamwork program is one way to systematically approach risk reduction within an organization. (Botwinick, L., Bisognano, M., & Harden, C., 2006) (Leonard, M., Frankel, A., Federico, F., Frush, K., & Haraden, C., 2013)
Introduction
Healthcare is focused on safety and quality outcomes, with a new emphasis on financial sanctions if positive outcomes are not achieved. Consumers are armed with information about outcomes and satisfaction. This has motivat...
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...Kohn LT, Corrigan & JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, 1999.
Leonard, M., Frankel, A., Federico, F., Frush, K., & Haraden, C., (2013) The Essential Guide for Patient Safety Officers (2 ed.)Oakdale Terrace, Illinois: The Joint Commission Recourses Inc.
Manser, T. (2008), Teamwork and patient safety in dynamic domains of healthcare: a review of
the literature, Acta Anaesthesiologica Scandinavica, February, 53(2), 143-151.
National Patient Safety Goals. TheJointCommission.http://www.jointcommission.org/standards_
information/npsgs.aspx. Accessed December 6, 2013.
Mazzocco, K, Petitti, D, Fong, K.T., Bonacum, D. Brookery, J., Graham, S., Laskey, R.E., Sexton, J. B., &Thomas, E., (2009) Surgical team behaviors and patient outcomes, The American Journal of Surgery197(5),678-685.
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
Human factors are derived from construction and adapted to a system of development in health care by carefully examining the relationship between people, environment, and technology. The consideration of human factors acknowledges the capability or inability to perform a precise task while executing multiple functions at once. Human factors provide an organized method to prevent errors and create exceptional efficiency. Careful attention must be exercised in all levels of care such as the physical, social, and external environment. It is also vital to carefully consider the type of work completed and the quality of performance. Applying human factors to the structure of healthcare can help reduce risks and improve outcomes for patients. This includes physical, behavioral, and cognitive performance which is important to a successful health care system that can prevent errors. A well-designed health care system can anticipate errors before they occur and not after the mistake has been committed. A culture of safety in nursing demands strong leadership that pays attention to variations in workloads, preventing interruptions at work, promotes communication and courtesy for everyone involved. Implementing a structure of human factors will guide research and provide a better understanding of a nurse’s complicated work environment. Nurses today are face challenges that affect patient safety such as heavy workloads, distractions, multiple tasks, and inadequate staffing. Poor communication and failure to comply with proper protocols can also adversely affect patient safety. Understanding human factors can help nurses prevent errors and improve quality of care. In order to standardize care the crew resource management program was
The Patient Safety Plan is a program that provides a systematic, coordinated and continuous methodology to the upkeep and upgrading of safety through the founding of mechanisms that support effective responses to definite incidences in an organization work environment. It is also the incorporation of patient safety main concern into new strategy in an organizational functions and services which would lead to continuous positive decrease of risk in the work environment. Patient safety plan is used as a guide to approach optimum safety objectives which involves different departments and disciplines in creating plans, processes and devices that contain the patient care safety activities in a hospital setting (Main Line Health Inc, 2011)
Institute for Healthcare Improvement. (2011). Introduction to the Culture of Safety (Educational Standards). Retrieved from IHI open school for health professions: http://www.ihi.org
In our organization we have had many revisions to our safety process. Originally, it was at our hospital that the 1996 well known “Willy King” incident, about the amputation of the “wrong” leg occurred. As a response to the incident, we were required to develop a root-cause-analysis and develop a plan to avoid similar situations in the future. We were one of the first hospitals to establish a “safety process” in the surgical environment. Through inter-disciplinary collaborati...
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.
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.
Strategies must touch upon all aspects of a complex work environment. According to Roux and Halstead (2009), some characteristics of an effective client safety culture consists of acknowledging human limitations, avoiding oversimplification of near miss or sentinel events, support from management and leadership in non-punitive problem solving approach in investigations, an interdisciplinary approach to collaboration which includes front line staff to enhance communication and reporting of concerns and errors, and training on intended changes prior to its development and implementation (p.
In study #3 was exploring the impact of “an inter-professional teamwork intervention in a surgical ward with regard to team decision making, patient safety culture and teamwork”. In the surgical department at 3 hospitals there was a questionnaire administered before to a controlled group. There was 6 hours of team training and execution of tools and strategies then 2 questionnaires afterwards (after 6 months and 12
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.
The importance of effective communication is clearly portrayed throughout the three themes discussed in this paper; collaboration, overall satisfaction, and patient-centered care. Without proper communication skills these three constructs can not properly function. When collaboration is utilized it not only improves patient-centered care but it improves overall satisfaction of staff and patients as well. These combined improve one of the major concepts in healthcare today, which is safety.
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,
It is right of a patient to be safe at health care organization. Patient comes to the hospital for the treatment not to get another disease. Patient safety is the most important issue for health care organizations. Patient safety events cost of thousands of deaths and millions of dollars an-nually. Even though the awareness of patient safety is spreading worldwide but still we have to accomplish many things to achieve safe environment for patients in the hospitals. Proper admin-istrative changes are required to keep health care organization safe. We need organizational changes, effective leadership, strong health care policies and effective health care laws to make patients safer.
And knowing limitations to these strengths is fundamental when developing a safe system. “When these system factors and the sensory, behavioral, and cognitive characteristics of providers are poorly matched, substandard outcomes frequently occur with respect to effort expended, quality of care, job satisfaction, and perhaps most important, the safety of patients” (Henriksen K, et al. 2008). The IOM also identified key factors to aid implementation of this principal, most of which seem common knowledge but are still not found as a standard from institution to institution These factors include: designing jobs for safety, avoiding reliance on memory, use constraints and forcing functions, avoiding reliance on vigilance, simplifying key processess, and standardization of work
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