Critical Incident Analysis Paper

The Healthcare field is becoming more aware of how important it is to change the way that organizational culture is becoming in order to help improve patient safety. Even though patient safety plays a very important part of our health care system which helps explain the importance quality of health care. However, when trying to keep patients safe, it can be a demanding challenge because of human errors and mistakes that are made. According to World Health Organization, patient safety is the absence of preventable harm to a patient while in the process of health care (who.int/patientsafety). Being in the position of a clinical content manager, the first step in reporting problems is to make sure that when reporting a problem, it need to be done at the earliest stage to show the importance to the company. The approach that I would take as a Clinical content manager is to identify the problem, have regular shift meetings to address any issues, flag any errors that occurred, have regular safety meeting, give feedback to staff on any errors that were found, try to figure out the best solution not only for the patients, but staff also, and although being a team leader, I would give the staff the opportunity to address any concerns that they may have.

Mulloy, D. F., & Hughes, R. G. (2008). Patient safety & quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.nlm.nih.gov/books/NBK2678/

When I learnt that I was going to be shadowing at a clinic for service users with drug and alcohol problems I was quite worried and intrigued as to what would take place. Then I realised I had to be holistic and also realistic, and although I am not close to anyone that has a heroin, crack cocaine or even an alcohol addiction I have been surrounded by people that have used certain drugs such as cannabis or cocaine. I also feel that I will not always know that this is the case as not everyone demonstrates through their behaviour that this is an issue for them, also some individuals feel ashamed as drug and alcohol use is frowned upon and individuals will deny using drugs. Some individuals explain that they use drugs as a way of numbing their problems or to gain confidence and self esteem. Beliefs about oneself and about the role of drugs or alcohol in one's life are sometimes called existential models (Greaves, 1980). Khantzian (1985) has proposed that addicts use drugs to offset

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Searches were made through the online library at Grand Canyon University. Results were refined to include on peer reviewed studies with keywords as combinations of: Safety briefing (45 results), patient safety plus nursing plus communication (1769), patient safety and interdisciplinary (45). Of the results obtained, the list was further refined to those studies that discussed the issue of communication in a team environment and risk of errors, or leadership follow up. Studies were not included if they were considered to be out of scope for the issue. Ultimately ten articles were identified as being pertinent to the subject, or had conclusions that could be extrapolated to the issue in question. From these search results four studies have been chosen for this paper to support the relevance of the issue.

The WGU nursing program helped me in developing my professional definition of quality and safety by enlightening my understanding of root cause analysis, and system failures. The IHI course was an eye opener in my understanding of quality improvement, and the processes required to enhance safety and quality improvement. The courses that really assisted me in my definition include, the Organizational Systems and Quality Leadership, the Leadership and Professional Image, and Professional Roles and Values; and the Evidence-Based Practice and Applied Nursing Research.

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

Given the complexity of healthcare system today, effective and efficient collaboration and communication among team members is critical to ensure patient safety. Daniel & Rosentein (2008) reported that during a typical patient’s hospital stay, a patient may interact with 50 different employees that may include doctors, nurses, laboratory technicians, etc. They also reported that when healthcare professional are not communicating and collaborating effectively, patient safety is at risk for several reasons: break in communication flow, misinterpretation of information, incorrect telephone orders and overlooked orders.

The purpose of this paper is to discuss how safety in the nursing profession affects the nursing education, nursing practice, and nursing research. Safety in the nursing profession means to minimize the risk of harm to patients and providers through both system effectiveness and individual performances (QSEN, 2014). Patient safety is a very important aspect in the profession of nursing. It is the nurse’s job to keep up to date with their patients and to make sure that protocol is being followed at all times. To maintain this strategy, the nurse must show proper knowledge of a nurse, skills of a nurse, and also a professional attitude.

In the 1990’s, the American Nurses Association (ANA) identified indicators which brought about the development of the Nursing’s Patient Safety and Quality Initiative (Miller & Soule, 2008). These indicators were specific to nursing,

As a nurse leader at Optum, suggesting strategies to achieve quality and safety improvement in health care requires critical thinking, analysis of health care trends, and collaborative relationships (Grossman & Valiga, 2012). This collaborative professional relationship requires a blame-free environment for a successful safety culture (Agency for Healthcare Research and Quality [AHRQ], 2016). As Optum strives to

Errors pervade in our lives whether it is our home, in our workplace, or in our society. The effects of healthcare errors have impacted all our lives either directly or indirectly. Patient safety and quality care are at the core of healthcare system which strongly depends upon nurses. “To achieve goals in patient safety and quality, thereby improve healthcare, nurses must assume the leadership role. Nurses need to ensure that they and other healthcare providers center healthcare on patients and their families. Even though the quality and safety of healthcare is heavily influenced by the complex nature

One thing that this website really stresses is the value of teamwork and being transparent with patient care on different levels. The purpose of an incident reporting system is to not necessarily focus on errors that occurred by individuals, but rather look at systems and see if there was a breakdown that occurred and what can be changed or implemented differently from preventing future errors from happening and potentially reaching the patient. The website can also be used to look at an organization as a whole and get healthcare leaders and executives to see the important role of patient safety and the impact that breakdowns can have not only on patients, but also the financial impact, which ultimately will impact the bottom line of any healthcare organization. At the facility where this writer is employed, whenever a safety event is reported, a team sits down to look at what happened before the event, during the event, and after the event. This approach is effective because the team involves individuals from different departments to gather ideas and thoughts about the incident, which was also discussed in the website about having the proper stakeholders present and advocating for patient safety (National Patient Safety Foundation, 2017). Overall, there are many factors that can have an impact on patient safety, but the National Patient Safety Foundation is a great source to start with when discussing ways to improve patient safety and utilizing the proper resources to initiate new practices and promote safer healthcare in the United

The patient problems of safety and quality care are applicable across the health care continuum. In a report released by the International Council of Nurses (2013) results from several research articles in support of the purpose for your proposed project are summarized. For example; in a multi-year study “increased workload, and unstable nursing unit environments were linked to negative patient outcomes including falls and medication errors …” (Duffield et al., 2011, p. 244). Specifically, researcher found “Lower levels of RN staffing are associated with higher rates of OPSN—urinary tract infections, pneumonia, shock and cardiac arrest, upper gastrointestinal (GI) bleeding, failure to rescue—and

Background - Healthcare organizations now face increasing pressure to improve their operations, provide evidence of their continued quality, and the efficiency of the organization. For the modern organization, this means that managers who have traditionally focused on the quality of care now must now change paradigms in mid-stream and review the overall management practice for the sake of effectiveness, patient safety, and even cutting edge techniques (Kujala & Lillrank, 2006). In fact, this is so critical that reports from the Institute of Medicine suggest that almost 60 per cent of medical errors related to hospital deaths in the United States could have been prevented with a proper safety protocol and change of procedure (Institute of Medicine, 2000).