Patient Safety Dilemmas

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.

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

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.

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.

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.

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.

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

Managers did not adequately assess the risk involved and were working within a malpractice culture outside of the guidelines and ignored the

The process of the nursing staff decided that it would be best to use restraints to prevent Mr. J from falling, in this situation with Mr. J developing redness to the lower spine, the UAP who noticed the redness should have alerted the Nurse who then implements a plan of action for skin breakdown, such as, a turning schedule, skin creams, skin protectants, and out of bed for meals, this would have prevented the outcome of a pressure injury. An UAP cannot function out of their scope of practice, by assessment of the client’s skin. The structure of the hospital should ensure client safety, the appropriate skill of the nurse and implement a plan that provides additional staff for turning clients that are unable to turn themselves. Through quality and client safety, hospitals should track clients that are admitted for falls, post- op, elderly, high risk for falls, history of falls, and high risk for pressure injuries. With the use of restraints clients are often confused in certain environments, nurses need to utilize least restrict measures to keep clients safe from falls, by placing them closer to the nurse’s station, hourly rounding, make sure call light is always close, and their needs are met.

Ensuring patient safety is a top priority throughout the healthcare industry. All healthcare organizations and hospitals alike have the ultimate goal of reducing and preventing inadvertent harm to patients as a result of their care (NKUSA, n.d.). Therefore, the actual key to patient safety is minimizing or eliminating harm to patients (NKUSA, n.d.). In reality, individual errors will never be totally eliminated, so the aim is to design systems that are “fault tolerant” so that the end result will not be harm to a patent, when an individual error happens, (NKUSA, n.d.).

In the IOM’s first report, "To Err is Human: Building a Safer Health System," they developed a comprehensive strategy for reducing the number of preventable medical errors and provider-caused injuries to patients. The report challenged government agencies, health care providers and industry leaders, and health care consumers to join the fight in reducing the number of preventable errors by 50 percent within a five year period. They established this goal based on the belief that the ability to achieve it is already within our grasps but faulty equipment, flawed processes, and a quantity-driven culture within many health care industries contribute to the increasing error rates and deaths among patients. Perhaps most alarming in the 1999 report was the estimation that “between 44,000 and 98,000 people died annually from preventable medical injuries. By comparison, less than 50,000 people died of Alzheimer’s disease and only a reported 17,000 people died of illicit drug use during that same year.” (American Hospital Association, 1999) Patient safety advocates across the globe were stunned but hopeful the report would spark a patient safety revolution. Remember that was 1999.

According to the Institute of Medicine (IOM) which has been on the forefront in undertaking research studies, pertaining to the prevalence of medical errors; systemic flaws are largely to be blamed for the high number of medical errors (BMJ Publishing Group Ltd 2011). The Hastings centre also shares the same sentiments when they state that “Many errors can be traced to flaws in complex systems of healthcare delivery, not flaws in individual performance” (The Hastings centre 2011, 5). These revelations come amid increased blame on healthcare workers for their apparent neglect of safe healthcare practices. IOM gives an example of poor communication between healthcare providers as one of the main problems

With observation of past and current patient safety trends in the U.S. Health industry, it becomes apparent that there are a multitude of procedural errors which often lead to patient malpractice. Therefore, it is crucial to identify the various aspects into the causes of procedural errors and patient care malpractice. By analyzing this data, management may utilize the information in establishing patient safety initiatives for their respective establishment. In addition, by increasing public awareness of patient safety, it will prove to

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help to improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are unfortunately preventable. But, it is clear that errors caused in healthcare thousands of deaths in the United States.

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.