Assignment task: Address a Patient Safety Issue
Introduction:
Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. "Quality and patient safety in health care have been on the forefront of the public's mind since the publication of the Institute of Medicine's (IOM) seminal report, 'To Err Is Human,' in 1999" (Johnson, Haskell, & Barach, 2016, p. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.
Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall.
Reference:
Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016). Case studies in patient safety. Jones & Bartlett Learning.
Preparation:
To successfully complete this assessment:
1. Review the following three scenarios from the Vila Health: Patient Safety simulation activity. Choose the scenario that interests you the most for further analysis in your assessment:
o Scenario 1: Patient Identification Error.
o Scenario 2: Medication Error.
o Scenario 3: HIPAA/Privacy Violation.
2. Review the Address a Patient Safety Issue Template [DOC] which you will use to complete this assessment. This document is formatted and has space for completing all components of the assessment.
Introduction:
For the scenario you selected, use the Address a Patient Safety Issue Template [DOC] to write a five-to-seven page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of the following in your paper and to address all of the points:
1. Apply the health care safety imperative to a patient safety issue.
o Identify the issue you selected from the Vila Health simulation as the potential safety threat.
o Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.
o Identify the implications of not addressing the threat.
2. Evaluate the risk to the patients, employees, and organization if patient safety threats are not addressed.
o What does the health care safety imperative say about the issue?
o How does the health care safety imperative apply in this case?
o Which regulatory agencies have oversight about the issue?
3. Analyze regulatory agencies' role and impact on organizations' patient safety programs.
o What specifically do the regulations state about the issue? For example, you might consider the Joint Commission's NPSGs.
o What impact do regulatory agencies have on organizations' patient safety programs?
o How do health care organizations incorporate regulatory agencies' guidance when establishing reporting and investigation best practices?
o What are the potential consequences to the patients, employees, and organization if the hospital fails to correct the threat?
4. Analyze the patient safety officer's role in implementing patient safety plans.
o Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.
o Clarify your responsibility and role as the patient safety officer in this specific instance.
o Provide one example from the literature to illustrate your points.
5. Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.
o Describe your five-point plan to reduce or eliminate this patient safety threat.
- What best practice tools or techniques do your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.
In a health care professional setting, recommendations to leadership would typically not be in APA format. However, your paper does need to conform to the current APA format and style guidelines. It does need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing. See the APA Module for more information about APA style.
Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references need to conform to APA guidelines.