Patient Safety Dilemmas

Data can be collected on multiple ways, from the point of medical care and patient satisfaction. The scenario points to pressure ulcers and the use of restraints, in both situations I believe that there was a fundamental lack of knowledge by the staff and disconnect by management.

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

Over the last 15 years or so a number of cases concerning patient care and safety have come to light prompting investigations and inquiries that have led to changes in the way care is delivered. These include inquiries at Winterbourne View hospital, Mid-Staffordshire hospital(Mid staffs) and Harold shipman to name a few.

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.

And if that does not satisfy the situation calling social service to investigate would be the next best possible action. The interview said; “They will inform the management by complaining as there is an open disclosure policy; if something goes wrong; and patient isn’t satisfied they could sue them. Which can indicated that the patients can file a case against facility if they feel that they two advised actions have not satisfied the negligence of the workplace. The most important key in deciding the best action to take for this case would be the patient’s satisfaction and finding justice for the suffering received.

Allows patients and families to call a medical emergency team when they feel they are in an emergent situation or their needs are not met.

Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what happened, why did it happen, what can be changed to prevent it from happening again and how are we going to evaluate the change. This process takes place soon after the event so details are not forgotten.

In 2011, over 3,800 of these “never events” where reported to the Joint Commission (psnet, n.d.). Being an Administrator in a hospital setting, it is import to know what SRE’s mostly occur. Many of the SRE’s reported in 2011 were linked to surgical events such as wrong-site surgery, air embolism, death or disability due to medication errors, patient suicide and environmental events such as fires, which can harm anyone in the facility (psnet, n.d.). 8.2% of the serious reportable events reported to the joint commission where medication errors, nearly 600 reports are medication errors. This happens when a patient dies or is seriously injured due to a medication error such as being administered the wrong drug or the wrong dose, it was given to the wrong patient, at the wrong time or wrong rate or had the wrong preparation, or wrong route of administration (psnet, n.d.). Mediation errors are the most important or relevant to hospital setting

An incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes, but also by changing staff attitudes and knowledge and working environment. In response, our organization developed many forum categories for specific incident type; however SRS suffer an unknown degree of underreporting, given that reporting is voluntary and spontaneous, and a systematic surveillance system is not feasible. Yet some staff those using the reporting system for accountability; wrongly interpret SRS data as valid rates of errors or as a valid measure of patient safety.

Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)

All health care professionals should understand the standards and practices of patient safety and safer care delivery. Error, mishaps, system problems and failures occur when providing patient care. System problems and failures can have both technical and human aspects. By understanding this concept, health care professionals can work to improve systems and lower instances of injury and harm (Milstead, 2014).

One ethical consideration is the staff that was called and did not attempt to make it into work according to our nurse manager’s statements. These employees will be counseled and reminded of the disaster relief policy. Another is in refusing to take responsibility for the death of the patient. If there was the proper amount of staff members on shift , the food allergy could have been discovered before improperly administering the wrong medication to the patient. Regardless of being short staffed it is the responsibility of the staff member to provide safety and that all medical questions are answered.  A third is that lack of responsibility for the falls. Staff members are required and ensure the safety of all patients and rounds should have been in full force. I also believe that patients should have been moved a open area so that it is easier to be able to see all patients. Although the patients may be awake and oriented, they may be suffering from effects of illness or medication that increase the likelihood of falls and this should have been addressed with the assessment that staff is required to do on all patients.

In effort to improve patient safety, the establishment of systematic reporting and measurements were implemented to track medical errors and healthcare quality issues. Several areas of progress include increased awareness, the development of reporting systems, and the establishment of national data collection standards. Various sources are utilized to examine patient safety and associated factors. Administrative data, medical records, reports, and patient surveys contribute toward the data collection process for patient safety review. The collection of

Major patient safety events are rarely a single error event. The events are usually a series of interrelated omissions or system errors. The following errors were noted:

These encounters make it cumbersome to classify alleviate primary causes of harm. Therefore, it affects the ability of the society to identify and prove the efficacy of patient safety risk management solutions that decrease medical errors and preventable serious safety events.