Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
Patient safety and risk management
Patient safety and risk management
Patient safety and risk management
Don’t take our word for it - see why 10 million students trust us with their essay needs.
Recommended: Patient safety and risk management
Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis.
Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root analysis is a systematic approach to collect information that may identify and evaluate hazards and risks (Williams, 2008). The root analysis provides a starting point on areas that may need changing. There are three areas to a root cause analysis of the adverse event which can enable the investigator to; 1) isolate the circumstances that increased the risk of an accident or incident from occurring; 2) determine who or what was involved in the situation; and (3) assess whether the facility might have control over the causes of the event (William, 2008). Using a report outline can help gather information consistency and completeness (Williams, 2008). The outline below evaluates the Samantha Jones adverse event.
1. Policy or Process (system) in Which the Event Occurred:
a. The policy or process did not confirm the correct patient
i. Nurses did not feel that they could voice their opinion about a proper time out
b. Time out was not conducted thoroughly
2. Human Resources (factors and issues)
a. No...
... middle of paper ...
...004). Root cause analysis applied to the investigation of serious untoward incidents in mental health services Retrieved from. http://pb.rcpsych.org/content/28/3/75.
Parker, D. (2008). Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF) Journal of Nursing Management; Mar2009, Vol. 17 Issue 2, p218-222.
Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (2008). The healthcare quality book. (2nd ed.). Chicago, IL: Health Administration Press.
Rooney, J.J. & Vanden Heuvel, L. N. (2004) Root Cause Analysis for Beginners. Retrieved from. https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdf
Williams, L. (2008) The value of a root cause analysis. Long-Term Living: For the Continuing Care Professional, Nov2008, Vol. 57 Is
middle of paper ... ... Root Cause Analysis in Response to a Sentinel Event. Retrieved on March 2014 from world wide web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdf Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors.
A root cause analysis is a mechanism used to determine if procedures prompt sentinel occasions. A sentinel occasion is characterized by Cherry and Jacob as "a startling event that can cause genuine physical or psychologic damage or the danger thereof." (Cherry and Jacob, 2011, p. 444) The goal of a root cause analysis is to distinguish the components which brought on the sentinel occasion and to recognize imperfections in the framework which can be adjusted with a specific end goal to keep a rehash of the occasion later on. A root cause analysis is not used to accuse people, and is not relevant when the occasion is deliberate, or brought on by carelessness or a criminal intent. Root cause analysis concentrates on disappointments in the framework
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...
A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.
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
National Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. S D Pearson, T H Lee, E Lindsey, T Hawkins, E F Cook, and L Goldman. (1994)
Blum,J.,(2011). Improving quality, lowering cost: The role of health care delivery system: U. S Department of health and human services.
Root cause analysis is a tool used by many businesses to determine why an event happened. This process is still rather new to the health care sector. In health care, root cause analysis can be helpful in several ways but there are limitations to its usefulness as well. The process for conducting a root cause analysis is not lengthy in terms of steps; however, it can take time to find all of the mitigating factors involved with the incident. The case study provided is a classic example of when and why a root cause analysis should be used in a health care setting. In addition, the discussion provided within the case study supports the use of root cause analysis in health care.
The form shall be posted on employee bulletin boards and shall be discussed in weekly safety meetings until all employees at the job site have been informed of the incident. Corrective Actions Resulting from Incident Investigations Incident investigations should result in corrective actions, individuals should be assigned responsibilities relative to the corrective actions, and these actions should be tracked to closure. Site Managers are held accountable for closing corrective actions. Corrective actions for safety improvement input are posted at each site and tracked by the COMPANY Safety Manager to ensure timely follow up and completion.
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).
Acquiring Information Whilst in the office Mark and I referred to the HSE LAC 22/13 ‘Incident Selection Criteria Guidance’. This is used to determine whether to investigate an accident or not.
The report was based around the notion that the fault of the incident was not that of the employee, but a result of the employer and the groups that are responsible for making and reinforcing the health and safety rules and
care for patients. In addition, the study will determine the factor of income and the burden of