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
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
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
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
Kohn, L. et al. 2000. To err is human: building a safer health system. Washington D.C. National Academies Press.
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.
Some research shows a connection between teamwork and reduced incivility in the workplace because a good team establishes a level of trust and effective communication, therefore, allowing nurses to feel empowered and supported (Logan, 2016, p. 48). Teamwork produces healthier environments with better healthcare outcomes. It is essential for staff to be proactive by attending staff meetings and committees such as shared governance and learn how to become effective mentors for new nurses.
Working in the health care setting, teamwork and collaboration are used frequently to insure that everything runs correctly and efficiently. According to qsen.org, teamwork and collaboration consists of functioning effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. While assessing the patient a nurse can come into contact and work with many different individuals. These can include other nurses, doctors, therapists, and family
The most commonly identified causes of these sentinel events include human factors, flawed leadership, and poor communication (“Sentinel event statistics released for 2014,” 2015). The concept of human factors can be applied to the individual, the healthcare team, and how a person performs and works within their environment (Doerhoff & Garrison, 2015). Individual human factors that have a negative impact on the delivery of patient care include cognition, fatigue, and physical ability (Doerhoff & Garrison, 2015). TJC has found that failed leadership within the healthcare setting fails to create a safe culture that allows sentinel events to occur (Ulrich, 2017). Hospital leaders can construct a culture of safety by focusing on accountability, recognizing unsafe conditions, trust, strengthening systems, and continually evaluating and assessing how they can improve patient and employee safety (Ulrich, 2017). Poorly communicating dietary restrictions, administration, and patient information amongst members of the healthcare team has significantly contributed to medical errors (Ulrich, 2017). From 1995 to 2015, TJC recognized ineffective communication as the leading root cause of sentinel events (Burgener,
Health care must be fully accountable for quality and the patient experience is simply the patient's perception of quality. Society should question and debate on how healthcare organizations should show improvement for consumers. This can help organizations create reliable health coverage cost and evaluate medical performances for families and individuals in the future. Physicians and organizations are now evaluating patients with collection of electronic data to improve a patient’s...
In today’s health care system, “quality” and “safety” are one in the same when it comes to patient care. As Florence Nightingale described our profession long ago, it takes work and vigilance to ensure we are doing the best we can to care for our patients. (Mitchell, 2008)
Kohn, L., Corrigan, J., & Donaldson, M. (1999). To err is human: building a safer health system. Committee on Quality of Health Care in America Institute of Medicine National Academy Press Washington, D.C.
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,
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).