Patient Safety Analysis

As health care has advanced through the years, many roles have changed which includes those of risk management and patient safety. Once thought to be one in the same,but they have distinct and obvious differences that set each apart from the other. Risk management is defined very broadly by the United States Inspector General of the Department of Health and Human Services as "any activities,process, or policy to reduce liability exposure"(https://oig.hhs.gov/oei/reports/oei-01-03-00050.pdf).This is much different from the definition of patient safety as found in the book Advances in Patient Safety: New Directions and Alternative Approaches as "Patient safety is a discipline in the health care sector that applies safety science methods

Patient safety is of utmost importance to prevent errors and adverse effects associated with patients in health care. Yet, 44,000 to 90,000 people die each year from preventable medical errors (Potter & Peter) caused by human factors. According to World Health Organization (2009) human factors is defined as:

A strategic plan is a tool that delivers guidance in achieving a mission or goal with maximum proficiency and control for an organization. Strategic planning is used to transform and revitalize organizations. The plan helps provide an inclusive understanding of opportunities and challenges both internally and externally for the organization. The plan delivers an assessment of the strengths and limitations that are realistic within the company. A well-developed strategic plan will offer a comprehensive approach and empowerment for the stakeholders involved. It is an opportunity for learning and understanding priorities that will drive the business to succeed. Jones (2010), describes how in health care organizations, strategic plans

Over time the health care industry has become more complex. Health care is rapidly evolving and continuing to complicate our delivery of care, which in turn has the same effect on quality of care. This steady evolution and change results in nursing shortages and an increase in the prevalence of errors being made. In hopes of preventing these errors and creating safe and high quality patient care, with the focus on new and improved ways of thinking, The Quality and Safety Education for Nurses (QSEN) initiative was developed. The QSEN focuses on the following competencies: patient-centered care, quality improvement, safety, and teamwork and collaboration. Their initiatives work to prepare and develop the knowledge, skills, and attitudes that are necessary to make improvements in the quality and safety of health care systems (Qsen.org, 2014).

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.

The National Patient Safety Goals were created in response to the IOM article, To Err is Human: Building Safer Health Systems. These goals were written to address patient safety and are tailored depending on the health care setting to which they are written for. They address system wide solutions rather than focusing on whom or how the error was made. Medical errors have been noted as being the 8th leading cause of death in the U.S. with the most frequent of these errors being medication related (Johnson, K., Bryant, C., Jenkins, M., Hiteshew, C., & Sobol, K. 2010). Therefore a great focus on these goals is needed across the health care continuum. The goals are updated and amended on a regular basis using evidence-based research, in response to areas with high errors in patient safety.

Our role is to make sure we are completing forms thourghly and submitting all required documentation, as well as codes regarding the patients diagnosis. This information is necessary in order to prove why the equipment is necessary for the

This paper, will discuss the National Patient Safety Goal NPSG 0.7.06.01 entitled “ Use proven guidelines to prevent infection of the urinary tract that are caused by catheter” (The Joint Commission, 2015). It will identify reasons why this National Patient Safety Goal was chosen as well as the type of organizations that utilize urinary catheters. It will look into financial implications of implementing educational process versus the hospital cost of Catheter-Associated Urinary Infections (CAUTI). The Advanced Practice Nurse (APN) will demonstrate method on how to gather data, design educational tool, implement standard practice and create a committee by collaborating with other health care discipline. Effectiveness of the educational process will be evaluated through data collection. Finally, future health care delivery implications will be explored.

The Pennsylvania Patient Safety Authority is a state agency founded by the Medical Care Availability and Reduction of Error (MCARE) on 2002. Moreover, the agency creates the greatest database system for patient safety which known as Pennsylvania Patient Safety Reporting System PA-PSRS. The system was developed by contract with Pennsylvania-based independent, ECRI, in partnership with Hewlett Packard Enterprise, a non-profit health services research agency, the Institute for Safe Medication Practices (ISMP), a Pennsylvania-based, non-profit health research organization and also a leading international information technology firm. Statewide compulsory for using PA-PSRS to report serious events in hospital, ambulatory surgical facilities and

It is a great opportunity to have this experience and to relate it with what we were being taught at school. There are a lot of connections in this project regarding patient safety. My safety project is a qualitative analysis of the difference between an allergy and sensitivity. The question still lies on how could the hospital staff manage allergy better?

In our nursing practice, the nurse is required to hold essential skills of clinical judgment and be a patient advocate to ensure the safety and the well-being of the patient we care for. Patient safety can be compromised if nurses are not able to identify potential issues thru assessment of the patient's sign and symptoms. Patient safety can also be compromised if nurses are afraid to speak up for our patient and question what we think or feel are unsafe acts or orders.

The Joint Commission established safety goals to help keep all clients safe in the healthcare. During this clinical, identifying clients is one of the safety goals that are followed. The nurse identifies the client using two identifiers; such as name and date of birth and verifies with the client’s name band. This ensures that the medical team gives the right treatments to the right client. Identifying client safety risks is another safety goal that is followed in the emergency room. The Bismarck Police Department brought a young man in for behavioral issues. The nurse places him in a room with a camera and the family sat in the room with him. I asked them what if there is no family present with these clients, who sits with them? The nurse

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Patient Safety Initiative, the American College of Surgeons (ACS), the New York State Department of Health (NYS DOH), and the Agency for Healthcare Research and Quality (AHRQ) have all developed regulatory and accreditation standards. For example, the JCAHO recommends that the surgical team pause and articulate the surgical site before commencing, to reduce medical error. Standards and accreditations include issues such as institutional hygiene and safety, as well as policy and procedure related to patient care.

This brochure “Patient Safety Systems” focuses on the commitment made by The Joint Commission to provide quality care and safety of patients which is extended to families, health care practitioners, staff, and health care organization leaders. It was published on October, 9, 2015. The information would benefit anyone in the health field including patients, their families, doctors, nurses, and leaders in any health facilities. It acts as a guiding tool to how health care system can be improved to provide better services to patients and provide them with safety.

Patient safety is a priority in a clinical setting. It is our duty at health care professionals to reduce the risk of harm. For instance, in a hospital setting medications errors, falls, infections occur often. This is unacceptable, which is the reason there are protocols, precautions, and competency modules taken to eliminate these problems. For an example, I had a patient who was diagnosed with a seizure disorder and was placed on seizure precautions. I placed pillows around the side rails to eliminate a possible injury. Also, many patients on the units I am on are placed on fall precautions and they each has a bed alarm set up to notify staff when they attempt to get out of beds. As far as infections, there are protocols that are in place