System Failure Essay

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

The main objective of Beaumont Hospital is to provide high quality, efficient, accessible services, in a caring environment for Southeastern Michigan residents. Beaumont Hospital believes that patient safety is just as important as medical progression. Therefore, Beaumont Hospital’s risk management program consists of identifying hazard associated risks, controlling risks, and monitoring the effectiveness of procedures/practices. Risk is a part of patient care and services because everything doesn’t always go according to plan. Catastrophic patient injuries often occur because of unanticipated failures. The risk management team is responsible of effective surveillance, analysis, and prevention of events which may injure patients, lead to malpractice claims, or cause loss to the health care system. The risk management staff at Beaumont use the Failure Mode and Effects Analysis (FMEA) as a tool to anticipate what might go wrong with a process or product and how that failure effects the patient. FMEA is designed to dissect a particular process into its individual steps, isolate the potential steps that could cause the problem, assign a specific risk level to each abnormal step, analyze the risk potential for the process, and assign and action plan to correct the problem (Fibuch & Ahmed, 2014). The risk management team also evaluates and modifies potential problems. Beaumont Hospital’s risk management team helps avoid or eliminate risks by identifying an alternate

Through basic observations, health professionals are able to evaluate the performance of an individual’s health status. In relation to Casey, it is noted in her Observation Chart that in the time span of two hours the patient’s health status had changed from being relatively normal (to the patient) to an increased respiratory rate, heart rate and temperature as well as a decrease in blood pressure. It is also noted that the patient has a score of 8 in the pain scale (compared to the score of zero two hours previously), relating to the lower abdomen. Programs such as Between the Flags acknowledges the fact that the early recognition of deterioration of patients can reduce harm to patients through designing and implementing systems which provide a structural response in the event of a deteriorating patient, such as Rapid Response and Clinical Review. There are two phases involved in the rapid response, which includes the afferent phase and the efferent phase. The afferent phase focuses on the overall monitoring and recognising the deteriorating patient whereas

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

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.

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 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.

To understand the rise in malpractice cases I would need to analyze each case separately. I would also need to find out how the system currently records and tracks medical errors and analyze any available information. I would also need to see safety reports if available.

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.

Institute for Healthcare Improvement. (2004). Failure mode and effects analysis (FMEA). Cambridge, MA: Institute for Healthcare Improvement.

Ashton, C., Kuykendall, David H., Johnson, Michael M. (1999). An Empirical Assessment of the Validity of Explicit and Implicit Process-of-Care Criteria for Quality Assessment. 27(8). 798-808.

Tables 1 - 4 present methods of evaluation for 4 short-term service outcomes. The template is of benefit when planning monitoring and evaluation. It helps set out the indicators appropriately for each outcome and then work out the ways of gathering necessary

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to