Evaluation Of A Patient Develops Pressure Ulcers

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was determined to be the best to prevent Never Events. Response to Dialogue of Nurses and Surgeons After reviewing the dialogue between the nurses and the surgeons, it was necessary to delve into the quality management method that were utilized in the hospital. Anytime a patient develops pressure ulcers, it is a sign of negligence in most cases. The surgeons are knowledgeable in knowing that the skin will breakdown with prolonged decreased bed mobility. Consequently, having a meeting to discuss changes in the quality assurance management methods is an indicator that there were some deficits in the delivery of healthcare. The fact that the Never Event occurred shows there was a breakdown in the quality assurance process in the hospital.…show more content…
The “Gold Practice” is a protocol to prevent Never Events from happening. According to Gitlow, 2013, reports showed that over 200,000 people were dying secondary to medical errors and acquired infection while in the hospital. In addition to this finding it indicated that one patient out of every 25 hospitals were injured by medical errors. Furthermore, an additional 6.1 million injuries were associated as a result of Never Events. Therefore, a proposal to reduce the occurrence of Never Events had to be incorporated into the hospital setting. To limit the Never Events, it required a collaboration model called “Breakthrough Series” which was developed in 2003 to provide the best practice protocols. It consisted of expert recruitment, enrollment of participating organizations and their teams, learning sessions, and action periods. The three most common Never Events are patient’s falls, pressure ulcers, and hospital acquired pneumonia. However, utilizing the “Breakthrough Series” can help reduced the three common Never Events are all controllable factors. Never Event Occurred Due to Inadequate Staffing In the scenario of the Never Event, per nursing and the surgeons it was determined that inadequate staffing was responsible for the Never Event occurrence. Inadequate staffing is a controllable entity. In my research a theory of inventive problem solving called TRIZ was designed to mitigate Never Events. TRIZ is a
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