Patient Safety Research Paper

Patient safety is number one in hospitals. Every staff member that comes into contact with a patient should always have the question, “Will the patient be safe?” in the back of

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:

Falls are one of the major patient safety problems that every facility encounter on a day to day basis. An aging patient population, combined with multiple diagnosis and medications are prime contributing factors for patient fall. Other contributing factors are shortage of nursing and auxiliary staff, ineffective work environment and shortage of appropriate equipment. According to the Joint Commission around 30-50 percent of the falls happening in the hospitals have resulted in injury to the patients. Since Joint Commission started keeping records of fall from 1995 to 2012, it has been reported that there were 659 fall related death or permanent disability, which were voluntarily reported as a

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.

Patient safety is a primary goal for all health care workers, especially Registered Nurses who are the primary care givers for many patients. To promote safety and well-being it is important to provide the best possible care to all patients without spreading hospital acquired infections to patients that were previously free from certain diseases. Clostridium difficile infections (CDI) are a common occurrence within health care settings and can cause many complications, increasing length of stay, and could even cause death.

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.

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.

In general, there is a need for patient safety improvements. However, the good new is, that there have been some slow improvements, including a better foundation to address patient safety. A good example is the annual Agency for Healthcare Research and Quality (AHRQ) survey designed to help healthcare organizations compare their safety record to other health care organizations. Over 600 hospitals participate each year in the volunteer survey. The results of the survey provide a baseline to track and evaluate patient safety interventions (Para. 15).

In health care settings across the country patient care is compromised by various preventable mistakes. Health care workers (HCW) are continuously pushing the boundaries of time constraints. As these demands are increased the possibility for poor patient outcomes also increase. Prevention is the first line of defense and promotes healthy practices for HCW and patients. The Joint Commission (TJC) collects data pertaining to the incidences, information surrounding each case and establishes a national quality and safety standard. TJC accredits thousands of health care establishments with the goal to provide safety and increase the quality of care provided in each setting. In 2016 TJC released a new set of National Patient Safety Goals (NPSG). The goals are meant to bring awareness to the accredited facilities and HCW of concerning hazards that need to be focused on. For instance, using two identifiers when identifying a patient to prevent medical errors, and preforming hand hygiene to reduce the risk of infections.

The problem I have chosen to decipher is patient falls in the healthcare setting. There are numerous ways to decrease the risk of falls, but today we will focus on prevention. Early prevention is the obvious key to avoiding falls. A contributing factor that goes hand in hand with prevention is communication amongst co-workers. As nurses, it is our job to be advocates for patients, and by using the correct tools given we can prevent these sentinel events. This problem was chosen because I currently work at a neuro rehab facility where falls are common due to severe neurological deficits. Personally, each time a patient falls my

Throughout our healthcare career, continuous change is occurring in the healthcare industry. However, this change does not always mean that there is continuous improvement. As healthcare providers, we often do not see the near medication misses, or the sources of harm, we certainly do not see ourselves as a source of injury. So how can we solve the issues of thousands of patients dying or being harmed in equipped, highly trained hospitals? We need to look into high-reliability organizations safety models. We need to be sensitive to operations, reluctant to simplify, aware of catastrophes and predict them instead of reacting to them, ask for advice, and have strength. These characteristics can help to reduce patient safety concerns and potential

In the 1966 film, Fantastic Voyage, world famous scientist Jan Benes suffers a stroke after being attacked on his way to the United State Combined Miniature Deterrent Forces (CMDF) lab. He possesses vital information that the US needs in order to defeat the Soviet Union, so they put Benes into a coma to prevent his brain from hurting itself further. Dr. Peter Duval, the lead surgeon, informs Mr. Benes’s Secret Service handler that the injured part of Benes’s brain is located in an area that they cannot operate on without fatally injuring the man. Their only option is to shrink an expert team of four engineers and scientists, along with Mr. Benes’s Secret Service handler, down to microscopic size and inject them through Jan Benes’s carotid artery

Patient safety is at the forefront of our minds when it comes to delivering safe and effective care. Alarms on clinical devices are intended to call the attention of caregivers to a patient or a device. Clinical alarms warn caregivers of immediate or potential adverse patient conditions. Alarm information can be transmitted away from the bedside to a remote location and such transmission may be disabled either intentionally or inadvertently. In 2005, the Joint Commission introduced a national patient safety goal requiring hospitals to reduce the risk of patient harm resulting from falls and to implement a falls-reduction program. In 2010, this requirement was upgraded to a standard. The Joint Commission cites bed exit alarms as both

Nurses always gives their best to provide better patient care for prevent the disease and promote the health. With the hourly rounding, they can prevent the falls, but sometime nurses can’t give hourly rounding because of shortage of nurses and this problem put the patient at high risk of fall. The best solution is maintaining the proper staff and talked with the manager or supervisor for help. Nurses needs to evaluate and provide safe environment around the patient. On admission ask the patient of previous number of falls. Discussion with patients and families about fall prevention measures for patient safety. During patient care nurses can use of tools visually such as, yellow socks, yellow tag, and magnets on patient locater board. Unfortunately,