Introduction. Health care entities across the U.S. manage their own medical mandates, each varying from state to state. States organize a set of mandates to ensure proper incident reporting. Health care organizations abide by such mandates in order to detect patient safety events and improve overall quality. The ensuing paper researches incident reporting systems from two separate states. Responsibility. Although not clearly stated, the responsibility of reporting incidents at both Utah and Minnesota institutions seemingly falls in the hands of every employee or health care professional. However, each mandate specifies to whom an incident should be reported. In Utah, each facility is obligated to report to the Utah Department of Administrative Services within seventy-hours of occurrence, and no later than four hours before a root cause analysis (RCA) is administered (UT Admin Code § R380-200-3-(1)). Incidents must be reported to the commissioner of the Department of Health in Minnesota as soon as possible, and no longer than fifteen working days after the discovery of the event (Minn. Statutes Code § 144.7065 Subd. 1). Types of Incidents. For two states that are nearly 1,300 miles apart, a general similarity rests amongst the types of required reported incidents. Both institutions detail almost identical events in slightly different formats. Health care facilities in Utah and Minnesota are instructed to report sentinel events relating to surgery, products or devices
The Healthcare field is becoming more aware of how important it is to change the way that organizational culture is becoming in order to help improve patient safety. Even though patient safety plays a very important part of our health care system which helps explain the importance quality of health care. However, when trying to keep patients safe, it can be a demanding challenge because of human errors and mistakes that are made. According to World Health Organization, patient safety is the absence of preventable harm to a patient while in the process of health care (who.int/patientsafety). Being in the position of a clinical content manager, the first step in reporting problems is to make sure that when reporting a problem, it need to be done at the earliest stage to show the importance to the company. The approach that I would take as a Clinical content manager is to identify the problem, have regular shift meetings to address any issues, flag any errors that occurred, have regular safety meeting, give feedback to staff on any errors that were found, try to figure out the best solution not only for the patients, but staff also, and although being a team leader, I would give the staff the opportunity to address any concerns that they may have.
The risk management program in any business, especially in a health care organization is an integral part of its day to day operation. The purpose of the risk management department is summed up by Kavaler & Alexander (2014), “…a program designed to reduce the incidence of preventable accidents and injuries to minimize the financial loss to the institution should any accident or injury occur” (p. 5). Protecting employees, patients, vendors and visitors is an ongoing process and one that needs to be updated when the healthcare organization has deemed necessary. This paper will demonstrate the importance of presenting the risk management program to new employees, compliance with the standards set forth by the American Society of Healthcare Risk Management (ASHRM), propose recommendations or changes needed to further improve the program, as well as examine the administrative process of managing a risk program.
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).
All healthcare workers are required to report anything that effects the environment. For example speaking to a senior staff member or manager straight away, explaining the problem so it can be dealt with properly. Reportable incidents: deaths, major injuries, some work-related diseases; dangerous occurrences – where something happens that does not result in an injury, but could have done; registered gas fitters must also report dangerous gas fittings they find, and gas conveyors/suppliers must report some flammable gas incidents. RIDDOR applies to all work activities but not all incidents are reportable
The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When
The RN/ Case Managers and Triage Nurses will increase their compliance of filling out incident reports that are being filled out by 10% within the next 3 months. The nurses will fill these out for patient falls, infections and injuries in order to be compliant with our Quality Assurance Goals.
We are the most technically advanced nation in the free world but yet we have not been able to reduce the number of firefighter fatalities over the years. Its one of the great mysteries of the world today. Our gear is better than what they wore thirty years ago, its better than what they wore ten years ago and we still lose an average of one hundred firefighters every year. I know that not all are dying in structure fires but just one is one too many.
The people responsible for reporting of injuries, diseases and dangerous occurrences regulations 1985 (RIDDOR) and the documentation of are the office manager and administrator. The law states that employers report:
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
3. The Safety Reporting System of the hospital has a policy in place for adverse reactions that state it is a voluntary online reporting. According to Joint Commission Standards an adverse reaction must be directly reported to the primary physician and quality assessment team.
Also enforced by OCR, the Patient Safety and Quality Improvement Act of 2005 (PSQIA) established a voluntary reporting system where data is analyzed and used to enhance the safety and quality of healthcare delivery. PSQIA provides confidentiality protections to healthcare providers who were previously concerned about the use of patient safety event reports in criminal, civil, and administrative proceedings. By limiting the use of event reports the fear report medical errors has decreased among many healthcare providers (Medical Errors and Patient Safety, 2008).
Each health care employer shall upon request, make available their findings and data for at least 5 years; 5) post a uniform notice that explains the standard and the procedures to report patient handling-related injuries. The notice must explains procedures to report patient handling-related injuries; and explains health care workers’ rights under this Act, including any whistleblower protections. Each health care employer shall conduct an annual written evaluation of the implementation of their programs.
For both Utah and Minnesota, health care facilities must report adverse events for serious patient injuries. The Utah Administrative Code requires that an independent, external review to be performed on the root cause analysis that is performed by the facility to ensure the credibility and thoroughness of the processes
The National Institute of Occupational Safety and Health will not change legislation regarding safety in the near future.
Fire prevention is a term being heard more and more today in America. It is starting to become a standard in today’s fire departments. Fire has the ability to keep us warm and also has the ability to make us homeless. As we grow as community and the technology changes, Fire Prevention needs to be made more of a necessity in our homes today. More homes are being built out of lighter material along with being built closer and closer together. Each can lead to extreme destruction, homes being lost, people being displaced, and even death. Why should we not protect homes and defend them against an enemy that can attack at any minute? Fire prevention needs to start in the home and then be carried onward in our lives. There are very