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Culture of patient safety essay
Essays on culture of safety in nursing
Culture of patient safety essay
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Organizational structure and culture in a health care organization is a complex phenomenon that reflects the social norms and beliefs of an organization. To effectively impact patient safety, health care organizations need to adopt a culture of safety. Organizations that practice high reliability, encourages a culture of safety. Adopting a culture of safety and high reliability is considered to be one of the most important factors in improving outcomes for hospitalized patients. High reliability organizations have a strong focus on patient safety, non-putative reporting of near-misses, and potential safety events. High reliability organizations promote 200% accountability. 100% accountable to the patient, and 100% accountable for an associates …show more content…
The Nursing Quality Council and the Professional Practice Council recognized this, and have implemented an evidence-based falls prevention team and program. Patient assessment using a universal falls protocol was implemented. Every patient is assessed for risk to fall using the ABC risk for injury assessment and the Morse fall scale. Reassessment of the patient’s risk to fall is completed on each shift, since a patient’s condition can change rapidly. Spoelstra et al. (2013), found reassessment of a patient’s risk to fall as one of the key interventions to preventing falls. Delirium an underappreciated contributing factor for falls. When patients are agitated or confused assessment of the level of confusion using the Confusion Assessment Method or CAM is utilized. If the CAM score is positive, there are guidelines for treatment and prevention of delirium. This includes measures to minimize delirium such as maintain day and night schedules, orientation to time, activities, and event’s (Babine et al., 2016). Enclosure beds, TABS alarms, hourly rounding, and red slippers-socks that indicated the patient is at risk to fall are all utilized. If the patient continues to be confused and agitated medications are administered, the most effective is Seroquel and part of the delirium protocol. Family engagement is encouraged and a care-partner program was implemented where either family or specially trained volunteers stays with the patient. When a fall does occur, there is a post fall huddle to discuss the cause of the fall and what could have been done to prevent the fall is conducted. The Joint Commission (TJC) recommends the use of a post fall huddle as a way to promote a culture of safety and to review the root cause of a patients fall. (The Joint Commission [TJC],
Jones, D., & Whitaker, T. (2011). Preventing falls in older people: assessment and interventions. Nursing Standard, 25(52), 50-55.
Dizziness is a common part of the aging process that can result from various factors including dehydration, malnutrition, peripheral and central disorders such as labyrinthitis; cardiovascular issues such as hypotension or the effects of certain medications (Fernández, Breinbauer & Delano, 2015). The nurse could speak with Mrs Jones to ascertain the type of dizziness that she experiences by identifying when the dizziness occurs and how often it occurs. If the dizziness is a result of dehydration or malnutrition, the nurse could recommend increasing fluid intake and refer Mrs Jones to a dietician to increase nutrient intake or if the dizziness is caused by any type of hypotension or inner ear problems, the nurse could refer Mrs Jones to her Doctor for treatment or provide strategies to reduce her symptoms (Bunn & Hooper, 2015; Fernández, Breinbauer & Delano, 2015; Gupta & Lipsitz,
The National Patient Safety Goal (NPSG) for falls in long term care facilities is to identify which patients are at risk for falling and to take action to prevent falls for these residents. (NPSG.09.02.01). There are five elements of performance for NPSG: 1. Assess the risk for falls, 2. Implement interventions to reduce falls based on the resident’s assessed risk, 3. Educate staff on the fall reduction program in time frames determined by the organization, 4. Educate the resident and, as needed, the family on any individualized fall reduction strategies, and 5. Evaluate the effectiveness of all fall reduction activities, including assessment,
This document’s purpose is to assist nurses to identify elderly patients at risk for falls and to implement interventions to prevent or decrease the number of falls and fall related injuries (RNAO, 2005). The target population are elderly adults in acute or long-term care. The recommendations are to help practitioners and patients make effective healthcare decisions, support nurses by giving educational recommendations, and to guide organizations in providing an environment receptive to quality nursing care and ongoing evaluation of guideline implementation and outcomes. These guidelines stress and interdisciplinary approach with ongoing communication and take patient preferences into consideration.
Falls can happen at any time and place in a hospital setting. It is a major patient safety issue causing injury, distress and even death. According to Debra Hain (2012), “In 2010, there were 2.35 million emergency room visits for non-fatal injuries in older adults with over 25% requiring hospitalization” (pg. 251). Falls can interrupt a person’s quality of life but also have a financial effect on the healthcare system (Hain, 2012). Falls are preventable and in order to reduce the rates for falls nurses must be more vigilant in their assessments to identify patients that are at risk, especially for those undergoing hemodialysis.
A fall is a lethal event that results from an amalgamation of both intrinsic and extrinsic factors which predispose an elderly person to the incident (Naqvi et al 2009). The frequency of hospital admission due to falls for older people in Australia, Canada, UK and Northern Ireland range from 1.6 to 3.0 per 10 000 population (WHO 2012). The prevalence of senior citizen’s falls in acute care settings varies widely and the danger of falling rises with escalating age or frailty. Falls of hospitalized older adults are one of the major patient safety issues in terms of morbidity, mortality, and decreased socialization (Swartzell et al. 2013). Because the multi-etiological factors contribute to the incidence and severity of falls in older society, each cause should be addressed or alleviated to prevent patient’s injuries during their hospital stay (Titler et al. 2011). Therefore, nursing interventions play a pivotal role in preventing patient injury related to hospital falls (Johnson et al. 2011). Unfortunately, the danger of falling rises with age and enormously affect one third of older people with ravages varying from minimal injury to incapacities, which may lead to premature death (Johnson et al. 2011). In addition, to the detrimental impacts on patient falls consequently affect the patient’s family members, care providers, and the health organization emotionally as well as financially (Ang et al. 2011). Even though falls in hospital affect young as well as older patients, the aged groups are more likely to get injured than the youth (Boltz et al. 2013). Devastating problems, which resulted from the falls, can c...
Falls are the leading cause of injuries, disabilities, and deaths among community-dwelling older adults (Moyer, 2012). According to the Center for Disease Control and Prevention (CDC, 2016), each year one out of three community-dwelling older adults aged 65 years or above falls at least once. There is a need to identify effective interventions pertinent to the primary-care setting to prevent falls among older adults living in the community. The guideline titled “Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement” is focused on determining the effectiveness and harms of different fall-prevention interventions relevant to primary care for adults aged 65 years or above (Moyer,
Patient falls in the hospital is a serious issue and challenging problem that could lead to prolonged hospital stay, longer recovery time for patients, increased costs for hospitals, and a source of distress and anxiety for patients, nurses, and families. Patient falls can cause minor or major serious physical injury depending on the situation and the age of the client. In addition to the physical harms, patients can suffer from psychological injuries which make them lose their independence and confidence on themselves and build a lot of anger, distress and fears of falling.
It is the hope and the goal of many hospital staff to help to decrease the number of falls in the hospital setting. The hope is to establish a plan that will assist nursing staff to decrease the number of falls. Falls can be extremely harmful to the elderly. Preventing falls is a much need goal that will bring better outcomes for the patient and the hospital. Evaluation of the action plan will also be planned for so that revisions can be made as needed to decrease the amount of patient falls.
Nurses are pivotal in hospital efforts to improve quality because they are in the best position to affect the care patients receive during their hospitalization. Data collection and analysis is the core of quality improvement assisting in understanding how the system work, identifying potential areas in need for improvement, monitoring the effectiveness of change and outcome. Nurses are also the eyes and ears of the hospital to positively influence patient outcome. For example, nurses are the ones catching medication errors, falls, and identifying barriers to delivering care. In this nurse’s facility, in order to minimize patient falls the hospital implemented a falls risk assessment tool called, “The Humpty Dumpty Scale” upon admission
In a culture of safety and quality, all employees are focused on upholding quality in providing safe care. In order to promote patient safety in the hospital setting there should be an exhibition of teamwork irrespective of the different leadership positions. However the leaders show their obligation to quality and safety, and set capacities for their employees to perform a committed and critical role in assuring patient safety.
Patient falls is one of the commonest events within the healthcare facilities that affect the safety of the patients. Preventing falls among patients requires various methods. Recognition, evaluation, and preventing of patient falls are great challenges for healthcare workers in providing a safe environment in any healthcare setting. Hospitals have come together to understand the contributing factors of falls, and to decrease their occurrence and resulting injuries or death. Risk of falls among patients is considered as a safety indicator in healthcare institutions due to this. Falls and related injuries have consistently been associated with the quality of nursing care and are included as a nursing-quality indicator monitored by the American Nurses Association, National Database of Nursing Quality Indicators and by the National Quality Forum. (NCBI)
Preventing falls in the elderly is of growing concern. Falls can lead to serious consequences such as fractures, fear of further falls, and loss of confidence (Breimaier, Halfens, & Lohrmann, 2015). These consequences have the possibility to significantly decrease the quality of life in a previously physically and socially active elderly individual. Discovering the most effective fall prevention strategy for the elderly population is a priority in healthcare. In reviewing the literature, various studies on the interventions and the perceptions of nurses for preventing falls in the elderly were examined in various settings such as the community, nursing homes, hospitals, and other acute care settings.
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.
Delirium is a mental state in which an individual is having a rapid disturbance in their cognition, attention, and awareness over a brief period of time. Delirium for an individual typically lasts for about one week, and hardly longer than one month. A treatment method for delirium would be to initially decide the underlying cause. Fluid and electrolyte balances are important components to monitor when an individual has delirium. Signs of hypoxia and anoxia are typical symptoms that may cause a patient to have delirium.