Patient Safety Goals Essay

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

Use at least two patient identifiers when providing care. Double checking of ID bands and ID/Driver’s license of patient if possible. Using labels to mark all materials /items needed for the procedures. A two person check off procedure must be implemented. Items requiring labeling include: patient records, signed consents, and all assessments, diagnostic tests and x-rays. Also included should be any item that is needed for the procedure (blood products, devices, and equipment). Using a matching system, so that all items in the procedure area are matched to the patient. The matching system must be completed by a minimum of two staff members. These staff members should include a qualified staff member, nursing staff involved in the procedure, recovery room staff, and discharge staff.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

As noted by Haugen, Murugesh, Haaverstad, Eide, and Softeland (2013) wrong site surgery continues to be a problem that can be prevented through the use of a checklist. In 2008, WHO published guidelines to ensure the safety of surgical patients. The guidelines included

Improve the accuracy of patient identification. The recommendation is for all healthcare providers to institute a policy of using at least two patient identifiers when providing care, treatment, and services. This goal has two objectives, one to verify the individual as the person for whom the service or treatment for and to match the service or treatment to that individual.

Over the last several years, a wide variety of health care organizations have been facing a number of challenges. This is because of pressures associated with: rising costs, increasing demands and larger numbers of patients. For many facilities this has created a situation where patient safety issues are often overlooked. This is because the staff is facing tremendous amounts of pressure, long hours and more patients. The combination of these factors has created a situation where a variety of hospitals need to improve their patient safety procedures. In the case of Sharp Memorial Hospital, they are focused on addressing these issues through different strategies. To fully understand how they are able to achieve these objectives requires looking at: specific ways the organization has responded to the crisis in medical errors, their definition of patient safety, the causes of errors, systematic barriers and transformations that have been adopted. Together, these different elements will provide the greatest insights as to how the facility is coping with the crisis in patient safety.

Briefing – This occurs pre-operative and is a meeting that includes all members of the surgery, from technicians, to anesthesiologist, to nurses and surgeons. It is a

Back in 2003, the Joint Commission created a National Patient Safety Goal due to 23 occurrences of death or injury to a patient where alarms had been applied incorrectly or the alarms had been muted (Sendelbach & Funk, 2013). By 2004, Joint Commission had removed it from their National Patient Safety Goal list and made it a requirement for Joint Commission accreditations (Sendelbach & Funk, 2013). In 2013, it was brought to the attention of the Joint Commission regarding many alarm-related events, including multiple deaths, permanent loss of function, and prolonged hospital stays due to health care worker’s decreased response times to alarms (Horkan, 2014; Joint Commission, 2013). The Joint Commission reinstated a National Patient Safety Goal in 2013 and had requirements for all hospitals that had to be met by July 1, 2014 (Joint Commission, 2013). These goals included being able to make alarm safety a priority and develop a plan to decrease the amount of alarms. This plan could include preventing unnecessary patient monitoring, clarifying who is allowed to monitor and silence alarms, setting the cardiac monitors to have multiple tones, and having a brief delay in the alarm to see if the patient can self-resolve. The second phase of the Joint Commission’s plan was to be implemented by January 2016, to where the hospital must have followed through with their designated plan (Joint Commission, 2013).

The National Patient Safety Goals were first developed in 2002 by the Joint Commission. The goals are established to help guide medical organizations to focus on which areas of patient safety need improving (Hudson 2016). The first set of goals were released and put in motion in 2003, prior to 2003 there were no policies or goals for an organization to set their sights on (Hudson 2016 page 2). A panel of experts advises the Joint Commission on the development of new goals or the updating of old ones. The panel is called the Patient Safety Advisory Group and is made up of nurses, risk managers, clinical engineers, and physicians (Hudson 2016). The National Patient Safety Goals have specific goals geared toward the type of medical organizations such as a critical access hospital, home care, behavioral health, and long term care services to name a few (Hudson 2016 page 2). The National Patient Safety Goals help protect patients and make sure providers are practicing safely across the board.

Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.

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

Wrong-site surgery has been identified as a top priority in improving quality of care and increasing patient safety. As such, The Joint Commission 2015 Hospital National Patient Safety Goal includes the prevention of mistakes in surgery. The goal is to perform the correct surgery on the correct patient at the correct site, prior marking of the surgical site, and performing a time-out just prior to commencement of the surgery. The purpose of this paper is to create a root-cause analysis, present recommendations for improvement, present recommendations to prevent wrong-site surgery, identify the stakeholders and role players, present root-cause analysis charts, and provide an overall of lessons learned throughout the course.

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

• Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency