Quality Dimensions And Measures Tables

A. The concept of Normal Accidents is as simple and as complex as the systems it describes. Bell relates to his readers a theory first presented by the sociologist Charles Perrow. The theory of Normal Accidents propose that today’s technologies have become both too complex and too intertwined for accidents to be avoided. As Bell points out, some systems, such as a nuclear power plant, are more complex than others, like a university. The complexity of the system depends upon how “coupled” each individual part is to one another, or in other words, how dependent or independent a component of a system is.

The Occupational Safety and Health Act purpose is to assure that individuals are working in safe environments. OSHA has been around for over 40 years and has come with many advantages as well as disadvantages. According to OSHA, “nursing homes and personal care facilities has had one the highest injury and illness rates, workers have faced numerous amounts of health hazards, and disorders compared to other work places”. These obstacles occurring in the health care work force has lead to the NYS Safe Patient Handling Act. This act consists of programs ensuring workers are better educated on how to prevent injuries, reduce disorders and improve quality of care towards patients.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

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

Patient safety is of major concern in healthcare settings due to the preventable nature of events that sometimes lead to serious injury, and even death, for patients. This was catapulted to the forefront of healthcare delivery in 1999 when the Institute of Medicine wrote a scathing report; To Err is Human: Building a Safer Health System, that highlighted "the lack of safety for patients in healthcare organizations" (Ulrich and Kear 2014). The National Patient Safety

Human interaction between individuals and systems does not occur in a vacuum, rather it occurs in a dynamic and multidimensional setting. From a structural and procedural system performance perspective, the nursing care environment “is perfectly designed to get the results it gets” (LLoyd, Murray, & Provost, 2015). When mistakes happen in healthcare, all Joint Commission accredited healthcare organizations are obligated to analyze the care environment to assess for opportunities to improve the structural and procedural elements that lead to care failures, as in the fictitious sentinel event case of Mr. B who presented to the emergency department for a

It is estimated that nearly 100,000 people die each year from medical errors in hospitals, with an estimated cost of between $17 and $29 billion per year. Finding a solution to this crisis has become a priority for every healthcare organization, with the realization that most errors are not caused by reckless staff, but by poor systems and processes (Institute of Medicine, 2000). Consequently, healthcare has begun to look to outside organizations in order to find solutions, by examining industries that are considered highly reliable, despite operating in hazardous situations. The lessons learned by these Highly Reliable Organizations (HROs) can be used to promote safe and reliable performance, which in turn should improve patient and staff

“Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures” (Stavrianopoulos, 2012, pg, 202). Communication and teamwork go hand and hand. An effective teamwork involves effective communication. No communication can lead to possible medical errors, whether the failure to communicate comes from the patient to the nurse or between the health care providers. Evidence based care is another factor which aids in safety. “Healthcare organizations that demonstrate evidence-based best practices, including standardized processes, protocols, checklists, and guidelines, are considered to exhibit a culture of safety” (Stavrianopoulos, 2012, pg, 203). Providing better safety means learning from the past mistakes. By understanding the root of the issue, which would then lead to learning how to improve the situation. Educational training about safety should be available for medical staff to attend and learn if there was to be any doubt in he or she’s mind. Patient centered care is another factor in providing safety. It focuses on the patient and their family. Helping patient’s and family be more active in the care of the health plan can lead to safer and better

The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. “To Err is Human: Building a Safer Health System” released information that reported that tens of thousands of Americans were dying each year from errors (IOM, 1999). Patient safety moved to the forefront in healthcare like never before and directives were discussed to put quality as a

Answer: As a part of a high-reliably organization, I am committed to 200% accountability and safety as the number one goal. Over the past year as an Informaticist, I have consistently advocated for patient safety and safe workflows. As an example, a new staff endocrinologist made a request to update the Insulin Basal Bolus Correction order set that was not evidence-based. I met with the endocrinologist to review the current practice guidelines per America Diabetes and Endocrinology Associations. During our discussion. the endocrinologist did not realize that there was the ability within the order set to make the desired changes to individualize the care and orders

As the patient safety officer, I am involved in the frequent root cause analysis (RCA) that result in improvements due to a retrospective response to specific events. Likewise, I am involved in many patient safety and quality initiatives where information from occurrences is used to improve quality, such as the falls prevention program, hospital-acquired pressure ulcer prevention, medication safety to name a few. These are broader approaches for improvement using a collaborative, multidisciplinary effort directed at improving the quality throughout the organization rather than a specific reaction

may help limit healthcare errors, and also hospitals ‘leaders have been encouraged for taking responsibility for making sure patient safety. This healthcare sector settled on a quality matter. Affected patient safety (PS) provides to have more staying power than previous quality initiatives such as continuous quality management(CQM) and also overall top quality management(TQM). It's different in important way: patient safety refers to genuine conditions that affect people's life.

In today’s health care system, “quality” and “safety” are one in the same when it comes to patient care. As Florence Nightingale described our profession long ago, it takes work and vigilance to ensure we are doing the best we can to care for our patients. (Mitchell, 2008)

The aim of this essay is to determine the inevitability of organisational accidents. An organisational accident is defined as an undesired or potentially disastrous event that is caused by the decisions and actions of the company. This essay will argue that organisational accidents cannot be avoided. As a first step, this essay will detail Perrow’s Normal Accident Theory in which he asserts that the implementation of complex systems by organisations / companies has resulted in unpreventable organisational accidents. The 2011 Fukasmi nuclear accident will be explained to support this assertion. As a second step, human error by those in the organisation as a factor which causes accidents will be analysed through Reason’s