The Quality Risk Management Plan

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

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).

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

As noted by Haugen, Murugesh, Haaverstad, Eide, and Softeland (2013) wrong site surgery continues to be a problem that can be prevented through the use of a checklist. In 2008, WHO published guidelines to ensure the safety of surgical patients. The guidelines included

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

Wrong-site surgery is a serious and preventable occurrence, however, it continues to be a problem in

Some of the most common medical mistakes are referred to as surgical never events. This is because it is believed that these errors are preventable, and thus, should not ever happen. According to the Agency for Healthcare Research and Quality, some of the most common surgical never events include the following:

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

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.

Mistakes in surgery such as wrong-site, wrong-patient, or wrong procedure occur all to often. These events are termed “sentinel events.” A sentinel event can be described as an accident or mistake that occurs in a hospital or other healthcare setting. These events can cause serious injury or death to a patient. Over the past few decades, major organizations such as the Joint Commission and the World Health Organization have put forth policies to try and decrease the incidence of these mistakes. In 2004 the Joint Commission developed the Universal Protocol. Under this protocol the patient must be identified, the surgical site must also be identified and needs to be marked, and lastly it states that there needs to be a time-out before any procedure occurs. This time out allows the surgical team an opportunity communicate and verify the procedure, the patient, and the correct surgical site. Shortly after this protocol was released, the World Health Organization released a similar protocol, but on a larger scale. This was the “Safe Surgery Saves Lives” campaign. This checklist was spread world wide and included three parts to ensure patient safety in all portions of the surgery; the sign-in phase, the time-out, and the sign-out phase.

You've heard those hospital horror stories where the surgeon removes the wrong body part oroperates on the wrong patient or accidentally leaves medical equipment in the person they were operating on.

A Wrong- site Surgery is defined as a Never Event where a surgery may be carried out on the wrong side of the body or on an incorrect body site. Events that involve surgery on the wrong body part, surgeries that involved incorrect procedure, or had a procedure intended for another patient are rightly termed Never Events. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are errors that should never occur and indicate serious underlying safety problems.

Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.

Wrong site surgeries are rare, however, they can be devastating to the patient and members of the surgical team (Carney, 2006). They are usually caused by not having a formal policy in place (Saufl, 2004). Multiple policies, including one by the WHO, are currently being utilized to prevent theses errors, however, they are still occurring, just at a reduced number. The goal of quality improvement is to prevent the issues from happening all together and increase the safety for the patient (Williams & Torrens, 2008).