The Common Adverse Event That Jeopardize Patient Safety

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 concern in the hospital setting. Missed nursing care due to high nurse patient ratios, or staffing issues leads to patient falls. Patient falls tend to be a big issue and expensive matter for hospitals nationwide. This paper will focus on a qualitative research article regarding missed nursing care, staffing, and patient falls. Included will be a summary of the research, methods and research used in the study, significance of the research findings, ethical considerations, and a conclusion.

I interviewed James Alviar RN, the Coordinator of Risk Management at my current place of employment the Queen's Medical Center West Oahu. I asked him if there were any current risk management issues at our facility that we could discuss, but he said all current issues were confidential and he could not divulge any information to me. Instead, James pointed me in the generic direction of hospital falls that is a nationwide risk management issue and also pertains to us at Queens Medical Center. This paper will be discussing risk management's role, what falls are, how falls are addressed, how risk

Townsend, Valle-Ortiz, and Sansweet (2016) article, “A Successful ED Fall Risk Program Using the Kinder 1 Fall Risk Assessment Tool” addresses an assessment tool for fall risk made for emergency department (ED) patients by ED nurses which was put into place upon arrival to the ED in Southern New Jersey. Patients who are aged 70 and up, mentally unstable, impaired mobility, or nursing judgement, they were labeled as high fall risk (Townsend et al., 2016). Townsend et al. (2016) continued by pointing out if any patient is at risk, fall precaution was enforced instantly, and the patient would receive a yellow band. Rounds per hour were also enforced.

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 the cost of implementing an educational process compared with the hospital cost of Catheter-Associated Urinary Infections (CAUTI). The Advanced Practice Nurse (APN) will demonstrate a method on how to gather data, design educational tool, implement standard practice and create a committee by collaborating with other health care disciplines. The effectiveness of the educational process will be evaluated through data collection and analysis. Finally, future health care delivery implications will be explored.

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.

The Pennsylvania Patient Safety Authority is a state agency founded by the Medical Care Availability and Reduction of Error (MCARE) on 2002. Moreover, the agency creates the greatest database system for patient safety which known as Pennsylvania Patient Safety Reporting System PA-PSRS. The system was developed by contract with Pennsylvania-based independent, ECRI, in partnership with Hewlett Packard Enterprise, a non-profit health services research agency, the Institute for Safe Medication Practices (ISMP), a Pennsylvania-based, non-profit health research organization and also a leading international information technology firm. Statewide compulsory for using PA-PSRS to report serious events in hospital, ambulatory surgical facilities and

Falls in a health care setting are costly to the patient, the health care facility and may affect the reimbursement that insurance gives to hospitals, yet they are preventable. Falls can be minor with just a few bumps and bruises or they can be major which can result in death. Not only are falls harmful to the patient but there is a lot of money and time that gets added up after a fall occurs *** There are many factors as to why a fall could take place, but being aware of the risk that a patient is a fall risk from the beginning can help avoid a fall from ever occurring. Accurately identifying a patient as a fall risk and communicating to other staff within 24 hours of admission is key to help in the prevention of falls.

Safety is the most important factor for patients receiving care within healthcare organizations. Health care workers and team members most especially nurses play an important role in the protection of the patients ensuring prevention of falls and injuries that occur as a result from falls. Falls are known to be the second leading cause of death from unintentional injuries worldwide (Mitchell, 2017). Nurses have the onus to keep their patients safe from falls and associated injuries daily. Patients that have been hospitalized are at higher risk of falls. Nurses have various tasks to be done per shift and it is important to ensure time is made available to meet

What nurse in an inpatient setting has not experienced the horrible feeling of feeling completely responsible for a patient fall? No matter how many checks, alarms, or rating tools employed, falls are an inevitable part of every nurses’ practice. The Joint Commission recognizes that falls are among the highest reported sentinel events for hospitalized patients. When a patient falls, it costs the hospital an average of $14,000 and adds over 6 days to the patient’s stay. (Quigley & White, 2013) In the article “Missed Nursing Care, Staffing, and Patient Falls” by Kalisch, Tschannen and Lee (2012) the authors examine whether patient falls are more impacted by inappropriate staffing, or missed nursing care. Through the process of

Tzeng and Yin (2008) state that nurses assume the responsibility and are liable when a patient falls in their care. Nurses spend the most time with patients at their bedside; however, nurses don’t have any

Patients may suffer injuries related to falls, which would be at the fault of the hospital/staff nurses.

The evidence based assessment tool, Morse Fall Scale is used to assess the risk for falls.

This study describes an acute care nurses’ experiences with patient falls in hospital settings. Patient falls have became a major public health concern in hospitals, thus safety is the main goal for the nursing

Incident reporting mechanism is an essential component in nursing occupation that facilitates the identification and monitoring of adverse events or incidents that occur during health care service. It is a defined procedures and protocols that should be place and disseminate throughout the organization. The reporting system is used to report occurrence such as falls, safety issues for patients, medication errors, treatment and procedural problems, and malfunctioning equipment. The benefit of incident reporting mechanism is to protect patient from injury or harm. In order to maximize patient safety, adverse events, mistakes and errors, and near misses incidents should be report in a timely and accurate manner. Furthermore, it is also used to make the nurse aware of inadequacies of her own part which make her reflect upon the situation and how this could be learned from, so as to prevent making same mistake again.