The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy. Quality and Safety Issue Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions. 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... ... middle of paper ... ...s throughout a patients stay, can significantly compromise patient care. I do not believe that anyone is willing to take that chance. Universal Protocol needs to be preconditioned, and then it is a fundamental value that is never going to change (Laureate Education, 2010). Works Cited AHC Media LLC. (2008, August). Joint commission revises universal protocol, clarifies who marks site. Same-Day Surgery, 32(8), 81-85. AORN. (2010, May). Perioperative news update. Retrieved from http://www.aorn.org/News/May2010News/NEWS/ Banschbach, S. K. (2009, February). Revisiting the universal protocol. AORN Journal, 89(2), 257-259. Dillion, K. A. (2008, September). Time out: An analysis. AORN Journal, 88(3), 437-442. Laureate Education, I. (Producer). (2010). Quality improvement and safety [DVD]. In The nurse leader: New perspectives on the profession. Baltimore. MD
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
There is nothing traumatizing in the world has adding pain to where it already exists. This is the hell situation which every medical error victim is exposed. As the statistics are currently showing, the fatalities are increasing day by day. The trend seems to be hiding on the old ideology of “man is to error”. However this is not being tolerated any more and the American medical facilities are being held 100% accountable for the mistakes they make in their service delivery. Professional diligence is not a matter of negotiation in this generation and probably future generations. If a medical facility cannot treat people diligently, then the only better option remaining for that facility is to be made to account for the losses they have caused on affected patients and be closed down immediately.
In order for hospitals to be reimbursed from government based insure companies certain standards must be met. When standards are not met, any subsequent cost in relationship to preventable errors will not be remunerated (Youngberg, 2011). These preventable errors are termed never events. Never events are considered error that can be prevented if certain checklist and guidelines are in place are followed such as medication errors, falls with injury, wrong surgical site, and pressure ulcers (Agency for Healthcare Research and Quality, 2012). There are currently ten mandated never events (Youngberg, 2011). In order to avoid these preventable human errors, risk manager help implement policies and procedure. This process based on risk analysis and outcomes which helps to improv...
Receiving the news that the patient was able to go home today endured that the patients outcomes were met. He also received the type of leg bag he preferred (ankle bag) for his catheter since he was to go home with it. He was briefed on his discharge information given a list of the medication he was to take including a new antibiotic for his UTI, and a referral to urology
...hould publish data on serious incidents for independent review” (Nursing Standard, 2014, p.10). In order to fully decrease the amount of never events occurring staff members need to be fully trained on how to properly use checklists, how to prepare for a surgery, and how to conclude a surgery. These trainings will stress the necessity of using checklists, and because of it most Never Events that transpire will only be serious occurrences.
According to agency of health care research and quality it is estimated that almost one third of health care spending is due to inpatient surgical procedures and it also estimates that average hospital costs has been increased from $ 9,100 in 2003 to $11,000 in 2013. [4] Some major reasons for this increase in costs includes lack of coordination, risk associated with complicated surgical procedures, poor patient engagement in decision making, quality requirements and etc. The perioperative surgical homes are very effective in solving these problems and achieve better surgical outcomes as it is a coordinated care which is led by multi specialty physicians who provides continuum of care to patients from the time of decision to 30 days after discharge of the patient i.e., it is incorporated in to include all three phases of surgery; perioperative, intra-operative and postoperative
The goal of patient safety is to prevent harm to patients Mitchell (n.d.). Patient safety in any health system is critical not only for the credibility of the system, but for patient trust and satisfaction as well. Adverse outcomes are defined as any injury or harm resulting from medical care (Watcher, 2008). Adverse outcomes can result in death and disability and cost the health system dearly. Bernard and Encinosa (2004) reported that in the U.S. it costs twice as much to care for patients that experienced adverse outcomes. The Institute of Medicine (IOM) (2000) reported that adverse outcomes cost the U.S. more than 16 billion dollars or 6% of total inpatient costs. Therefore, adverse events are costly both in terms of human life and fiscal resources.
Fierce healthcare reported sometime in June of 2012 that hospitals across the country had received safety report cards from one Leapfrog group. They reported that most facilities got a C or below in the rankings. The report also showed that the biggest hospitals such as the Henry Ford Hospital in Michigan barely got a passing grade. The report cards were meant to inform patients and also to motivate improvements in patient safety, they were faced with a lot of criticism and controversy especially from hospitals that did not pass. This paper will discuss the controversy facing patient safety in the U.S. It will also analyze the effects of the issue and the solutions suggested and currently in place to solve the issue.
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.
Every hospital is committed to ensuring that their patients in stroke rehabilitation wards and other facilities are safe from any form of harm that may occur as a result of the health care providers’ negligence. Firstly, every hospital integrates quality and safety approaches into its everyday’s operations to promote and enhance the safety and quality of its environment and services respectively (Garban, 2011). This is usually complemented by other strategies meant for enhancing organizational knowledge to improve efficiency and overall productivity. Some hospitals provide further training to their health care personnel to ensure that they efficiently incorpor...
Complex patient care problems make communication between team members, patients, and family members very important. Collaboration to provide the best practice options are crucial for the best patient outcomes. Patients put their trust in their medical team to gather all information available to come up with a plan of care that will benefit the patient. The Joint Commission introduced the National Patient Safety Goals in 2005, communication among team members plays a huge role in that goal (Ward, 2012).
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
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
The “Never Events” is in reference to medical errors that should never occur. Never Events are defined as medical and surgical errors of wrong site surgery, delay in treatment, medication error, wrong procedure performed on patient, suicide, and death by patient using contaminated drugs. The list was altered since then, recently in 2011 and now contains of 29 events gathered in six categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal, stated by, (Patient Safety Network Agency for Health care Research and Quality, 2014). The ramifications of such a policy for pros are the useful awareness being reached out to hospitals, and other health facilities to be mindful of errors. Another