The Organized System Approach to Improving Patient Safety (Essay Sample)

Patient Safety
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Patient Safety
Abstract
Patient safety is an aspect of healthcare quality that involves the prevention, analysis and reporting of process errors which could result to adverse health events. Health care providers occasionally harm their patients unintentionally and subject them to adverse events such as hospital-acquired infections, medication error, surgical complications, blood infection and many others. According to a report by the Institute of Medicine (IOM), up to 98,000 people in America die as a result of medical errors each year (Donaldson et al., 2000). The patient safety initiatives seek to measure the safety of the patient, assess the measurements results and make the necessary improvements. The objective should be to reduce the risk of errors and in the event that errors occur, appropriate safeguards should be put in place to ensure that the error does not harm the patient (Spath, P. 2009). This essay will discuss the organized system approach to improving patient safety. Specific focus will be on the prevention of the medical errors that cause harm to patients. In addition, the essay will discuss the measuring of patient safety performance in order to improve patient outcomes, care processes, and health structures in the clinical setting. Finally, the essay will discuss patient safety improvement through root cause analysis (RCA) and failure mode effects (FMEA).
Patient Safety
Over the years, patient safety in healthcare has increasingly received attention as a serious global health issue due to the high number of patients who are harmed while in a healthcare setting. Patient safety is an aspect of healthcare quality that involves the prevention, analysis, and reporting of process errors which could result in adverse health events. The crucial aspect of patient safety is not causing harm to the patient and all health professionals are expected to espouse that principle. However, caregivers occasionally harm their patients unintentionally and subject them to adverse events such as hospital-acquired infections, medication error, surgical complications, blood infection and many others (Spath, P. 2009, pg. 173). According to a report by the Institute of Medicine (IOM), up to 98,000 people in America die as a result of medical errors each year (Donaldson et al., 2000). Although most medical errors are preventable, the number of patients who die due to medical errors exceed those who die from diseases such as cancer, HIV, or even traffic accidents. The outcry on patient safety led to the adoption of safety programs which focus on activities such as emergency preparedness, risk management, radiation safety, management of hazardous materials, hygiene, preventive measures, and environmental safety. Improving patient safety requires an organized systematic approach to quality management components so as to prevent medical errors, measure patient safety performance and improve the safety of patient care through root cause analysis (RCA) and failure mode effects (FMEA).
Prevention of medical errors that harm patients is an issue that has been constantly neglected. Traditionally, prevention of errors was entrusted to persons providing care including nurses, doctors, clerical staffs, technicians, and other staff. However, even vigilant health professionals may not detect all errors thus making systems that rely on human performance to be flawed (Donaldson et al., 2000). Most mistakes are unintentional and result from situations beyond the control of the healthcare provider. In order to promote patient safety, an organized system improvement is required to reduce the chances that errors will occur and the minimize the chances of patients being harmed. The objective should be to reduce the risk of errors and in the event that errors occur, appropriate safeguards should be put in place to ensure that the error does not harm the patient (Spath, P. 2009).
According to Cohen (1999), most medical errors occur due to the complexity of the patient care processes. The variables involved in patient care makes even the simple process to be complex. For instance, obtaining a blood specimen from a patient includes variables such as the location of the patient, the method of specimen collection, the vials for blood storage, the type of laboratory testing and the reporting of the results. An error may occur in any of these variables which in turn affect the accuracy of the results. In order to ensure the patient’s safety, the care processes should be restructured to minimize the risk of errors or make it impossible to make mistakes. This can be done by adding safeguards that catch and correct an error before it causes harm to a patient (Spath, P. 2009). For instance, a surgeon might forget a sponge inside a patient’s abdomen, as a safeguard, the nurse may do a sponge count and inform the surgeon of the missing sponge which would then be removed before closing the incision. The safeguards can be adopted in various patient care process in order to detect and remedy any mistakes. Besides the safeguards, healthcare organizations have been espousing other error prevention techniques and strategies that are used in other industries such as patient registration, billing, hazard control among others (Lehmann, 2005).
Measuring patient safety performance is a quality management activity that aims at discovering and fixing problems before they cause adverse events. Patient safety initiatives seek to measure the safety of the patient, assess the measurements results and make the necessary improvements. Just like any other performance measurements, the safety measures alert health care providers about potential threats to patient’s safety before they occur (Spath, P. 2009). The urgency in patient safety requires health professional to take part in measuring and improving patient outcomes, care processes, and health structures in the clinical setting (Poe, 2005). According to Poe (2005), measuring patients outcomes allows the health professionals to quantify the attributes of processes and structures that protect patients from harm as well as their adverse or favorable effects on patients. For instance, in order to protect patients from an adverse reaction to drugs, a measure can be adapted to determine the average number of adverse reaction events per 1,000 doses. This will help in identifying the performance of safety measures in protecting patients from adverse drug reactions. The report from the measurement enables health organizations to redesign the patient care if necessary in order to prevent future occurrences (Poe, 2005).
Health care providers can also complete incident reports to document actual or potential safety threats to patients such as patient fall, treatment error, nosocomial infections, adverse reaction to blood transfusion, malfunctioned medical devices and many others. The incident reports provide information about the patterns of events that threaten the patient’s safety and health professionals can use the report to prevent future harm to the patient (Spath, P. 2009). In order to ensure that health care providers report all the incidents that cause harm or present potential harm to patients, there should be safeguards to protect the staff from unintentional mistakes. Some states have adopted a state reporting system to publicly report the number and type of patient safety incidents. The Patient Safety and Quality Improvement Act of 2005 had strategies of developing a national patient incident database to enable the identification of the causes of hazards and risks to patient’s safety through analyzing the incidents from different facilities (Iacovelli & Levy, 2009).
Patient safety can be improved by using the Root Cause Analysis (RCA) to analyze current practices and determine process defects that resulted in the harm to the patient. The RCA has been in use for many years and in many industries to investigate the root causes that led to the occurrence of an adverse event. According to the Joint Commission (2007), RCA should be done after an occurrence of a sentinel event. The sentinel event is used to refer to an incident involving a serious injury or death to a patient and conducting a root cause analysis is likely to reveal inherent safety problems (Uberoi, Gupta & Sibal, 2007). A root cause analysis should also be conducted even when an incident did not result in injury or death but the even was near a miss (Spath, P., 2009). Healthcare professionals should consider incident events as signals to defects in the care processes. Treating symptoms of a disease doesn’t address the root cause of the problem but the symptoms are signals that a problem exists. For instance, if a hospitalized patient is given the wrong medication, it is an indication of an inherent problem within the drug administration process. If the problem with the medication process is not addressed, there is a likelihood that the wrong drugs will be administered in the future (Spath, P. 2009).
The root cause analysis follows six steps which involve identifying what happened, identifying the root causes, developing risk reduction strategies, implementing the risk reduction strategies, retesting the strategies, and evaluating the effectiveness of the strategies. When conducting RCA to improve safety in patient care, it is imperative to first identify the causal factors which may be circumstances, situations or conditions. The second step involves the identification of the root causes of why the event occurred. This can be done by questioning the “why” for each of the causal factors of the adverse event. After analyzing 4,977 se...