Risk and Quality Managment Assessment

The quality department has developed this manual to introduce new employees to the basic concepts of risk and quality management within the institution. This manual meets the institution’s initiative for continuous quality improvement within each department and the opportunity to mitigate areas of risk whenever possible. In order to accomplish this goal, it is important for the new employee to be able to identify what quality improvement and risk management mean within the institution. The institution believes that when employees are aware of these concepts, decision-making processes can be put in place to reduce risk and improve quality. This manual will also review the challenges that come from risk- and quality-management decisions especially in the health care setting. The new employee will be introduced to a variety of tools available to help assess potential problems, determine whether a change is needed and how to institute these changes through informed decision making. A clear understanding of how to use these tools will help the institution reach their goals of patient-centered care while providing a safe environment. Risk and quality management initiatives have the potential to save lives and save the institution money. The institution believes that successful risk and quality management is achieved only through employee awareness and incentives to provide a culture of safety.

Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.

According to the Food and Drug Administration (FDA 2009), the wrong route of administrating medication accounts for 1.3 million injuries each year. An article published in September issue of the Journal of Patient Safety estimates there are between 210,000 and 400,000 deaths per year associated with medical errors. This makes medical errors the third leading cause of deaths in the United States, behind that comes heart disease and cancer. To prevent medical errors always follow the Three Checks and most importantly the Rights of Medication Administration. The “Rights of Medication Administration” helps to ensure accuracy when administering medication to a patient. When administering medication the administer should ensure they have the Right Medication, Right Patient, Right Dosage, Right Route, Right Time, Right Route, Right Reason, and Right Documentation. Also remember the patient has the right to refuse, assess patient for pain, and always assess the patient for signs of effects.

Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of

Risk management is about reducing the likelihood of errors with the aim of improving and monitoring the quality of health care services. The purpose for risk and quality management is to improve the care of the patients and reduce liability among the staff and the patients. In following risk and quality management protocols

One of the standards that has been implemented is Standard 4: Medication Safety. The Australian Commission implemented this standard with the intention of ensuring that competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and monitor the effect. (Australian Commission on Safety and Quality in Health Care, 2012) In healthcare, one of the most common treatments is medication. As a result of this, there are many incidences of error, many more than any other healthcare interventions. According to the Patient Safety Network (PS Network, 2015) medication errors account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Medication errors are often a result of the unsafe and poor quality practice of healthcare professionals or system errors. Medication errors are costly and many are avoidable. For this standard

Errors made while administering medications is one of the most common health care errors reported. It is estimated that 7,000 hospitals deaths yearly are attributed to medication administration errors.

There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.

For many patients the scariest part of being in the hospital is having to rely on other people to control your life changing decisions. One large part of this is the medications one is given while in our care. I can only imagine what it must be like for patients to have a stranger to come in and start administering drugs to me. This would be especially scary if I did not know what these medications did, or what negative effects could be caused by taking them. Unfortunately, the fear of medication errors that many patients have are not unfounded. Estimates range from 1.5 to 66 million patients a year have medication errors occur while they are in the care of health care professionals. Considering all of the technology we have at our

An organization risk manager and quality manager are continually seeking useful ways on minimizing risks to the organization and promoting better care of the patient. Risk management is the series of actions that is put forward to identify and address the issues to avoid the possibility of loss or injury. “Moreover, even when a risk-management plan creates barriers to access, a careful discussion of those barriers can lead to strategies to reduce them” (Meltzer, 2007, pg. 2). Quality management oversees the development of a product or service and ensures that it’s functioning or performing in the best possible manner with the least waste of time and effort. These departments are critical in recognizing and protecting a company loss. Many health care professionals not easily persuaded that quality can improve even though the result is not good

Medication error is defined as the following by the National Coordinating Council for Medication Error Reporting and Prevention: “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010). Medication errors cause increased length of patient hospitalization and morbidity and mortality (Pape

It is evident that patient safety is one of the most important principal in place as a nurse. To insure this there are many standards that are set in place that as a registered nurse need to be met, some including, professional responsibility and accountability, having knowledge based practice, ethical practice, service to the public and self-regulation (SRNA, 2014). “These standards and foundation competencies serve as the criteria against which all registered nurses, practising in all domains of nursing practice (direct care, education, administration, and research, and the evolving domain of policy) will be measured by clients, employers, colleagues and themselves”(SRNA, 2014). Having these standards allows register nurses and the public to have a clear understanding of what needs to be met in order to insure that there is proper patient safety. However there are still many issues that contribute to unacceptable patient safety, including medication administration errors, post operative care, and patients mental health. However, “medication errors are one of the most common types of medical errors that occur in healthcare institutions” (J.Choo, 2010). A medication error, according to The National Coordinating Council for Medication Error Reporting and Prevention “is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or

Evergreen Woods health and rehabilitation center is located in Spring Hill Florida. The center has been serving Hernando County for over 25 years. Services that the center offers are: Post-acute services, Rehabilitative services, skilled nursing, Short and long term care through physical, occupational and speech therapists. The mission of Evergreen Woods health and rehabilitation center is to provide comprehensive services to meet the care of the residents and patients. They strive to meet customer satisfaction daily and follow core values to obtain excellence in care.

Risk Management and Quality Improvement/ Together At Last-Part 2 By: Darr, K, Hospital Topics; 1999 Spring Vol. 77, Issue 2

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error