The Common Adverse Event That Jeopardize Patient Safety

Mary Surratt was sentenced to death by hanging for aiding in the president's assassins. She helped John Wilkes Booth and his associates kill president Lincoln and attempt to kill vice president Seward. I think Mary Surratt was guilty of aiding the president's assassins and attempting to help kidnap the president and i will tell you why.

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

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

This program is “an online tool that facilitates audit, compliance reporting and feedback, and action plan formation. It allows baseline audit and follow-up auditing cycles” (pg. 269). Through this program, a project team was established and audit criteria was created. The criteria used for the project were as follows, (1) fall risk assessment is done on admission (2) fall risk assessment is done with transfers (3) fall risk assessment is done with a change in condition (4) Patient who experienced a fall is considered high risk for future falls (5) Fall risk assessment is done accurately using fall assessment tool (6) Healthcare providers have received education regarding fall assessment and prevention strategies (7) Patient education is carried out for patients at risk of falls (8) Targeted interventions are implemented according to risk factors. Each of the criteria was implemented in a hospital setting and after 1 year and 2 years, the hospital was re-assessed with a follow-up audit.

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

Patient safety should be the top priorty of every hospital and medical professional. Unfortunately it seems that priority gets lost sometimes in the business of health care. For example, the national death rate from a knee replacement surgery is about 1 in 1000. Patients that have that surgery done at a hospital that does not regularly perform it are 3 times more likely to die. However a recent story on National Public Radio highlighted some positive steps a few of the countries leading teaching hospitals are taking to prevent unnecessary risks to the safety of their patients.

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.

Have you ever admired anyone in your life to the point that this person seems like he or she is more than human or God like. In F. Scott Fitzgerald’s, The Great Gatsby, the main character, Nick, introduces Jay Gatsby in a divine like way even though he does not really know much about him at this point. As the story progresses, a series of events that occur guide Nick to finding out the truth about Gatsby. His view of Gatsby clearly changes through this period of time and Nick begins to picture Gatsby as a regular human being who is not much different than him. Nick portrays Gatsby as a divine figure because Nick does not know Gatsby’s hidden truths, but as Nick begins to learn the truth, Gatsby loses his angelic characteristics.

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

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).

Issues related to a lack of patient safety have been going on for a lot of years now. Throughout the first decade of the 21st century, there has been a national emphasis on cultivating patient safety. Patient safety is a global issue, that touches countries at all levels of expansion and is one of the nation's most determined health care tests. According to the Institute of Medicine (1999), they have measured that as many as 48,000 to 88,000 people are dying in U.S. hospitals each year as the result of lapses in patient safety. Estimates of the size of the problem on this are scarce particularly in developing countries; it is likely that millions of patients worldwide could suffer disabling injuries or death every year due to unsafe medical care. Risk and safety have always been uninterruptedly been significant concerns in the hospital industry. Patient safety is a very much important part of our health care system and it really

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.

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.

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.

My major paper is going to be about my father. It is going to include all different types of things about him but it will probably be mostly about why i hate him so much. I chose this subject because it is something sensitive to me. Everyday it is a heart break to me because i do not fully understand why he does the things he does. It simply does not make sense how a father could be so terrible. I look around at everyone else who has a dad or at least grew up with a dad and it aggravates me because i never got the chance with that.