Pennsvania Patient Safety Research Paper

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

As health care has advanced through the years, many roles have changed which includes those of risk management and patient safety. Once thought to be one in the same,but they have distinct and obvious differences that set each apart from the other. Risk management is defined very broadly by the United States Inspector General of the Department of Health and Human Services as "any activities,process, or policy to reduce liability exposure"(https://oig.hhs.gov/oei/reports/oei-01-03-00050.pdf).This is much different from the definition of patient safety as found in the book Advances in Patient Safety: New Directions and Alternative Approaches as "Patient safety is a discipline in the health care sector that applies safety science methods

Over time the health care industry has become more complex. Health care is rapidly evolving and continuing to complicate our delivery of care, which in turn has the same effect on quality of care. This steady evolution and change results in nursing shortages and an increase in the prevalence of errors being made. In hopes of preventing these errors and creating safe and high quality patient care, with the focus on new and improved ways of thinking, The Quality and Safety Education for Nurses (QSEN) initiative was developed. The QSEN focuses on the following competencies: patient-centered care, quality improvement, safety, and teamwork and collaboration. Their initiatives work to prepare and develop the knowledge, skills, and attitudes that are necessary to make improvements in the quality and safety of health care systems (Qsen.org, 2014).

One of the standards that has been implemented is Standard 4: Medication Safety. The Australian Commission implemented this standard with the intention of ensuring that competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and monitor the effect. (Australian Commission on Safety and Quality in Health Care, 2012) In healthcare, one of the most common treatments is medication. As a result of this, there are many incidences of error, many more than any other healthcare interventions. According to the Patient Safety Network (PS Network, 2015) medication errors account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Medication errors are often a result of the unsafe and poor quality practice of healthcare professionals or system errors. Medication errors are costly and many are avoidable. For this standard

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).

The National Patient Safety Goals were created in response to the IOM article, To Err is Human: Building Safer Health Systems. These goals were written to address patient safety and are tailored depending on the health care setting to which they are written for. They address system wide solutions rather than focusing on whom or how the error was made. Medical errors have been noted as being the 8th leading cause of death in the U.S. with the most frequent of these errors being medication related (Johnson, K., Bryant, C., Jenkins, M., Hiteshew, C., & Sobol, K. 2010). Therefore a great focus on these goals is needed across the health care continuum. The goals are updated and amended on a regular basis using evidence-based research, in response to areas with high errors in patient safety.

In addition to the core objectives, eligible professionals must also meet 5 out of 10 from the menu set of objectives. The lists of menu objectives are as follows.

Charles, K., Cannon, M., Hall, R., & Coustasse, A. (2014, October 1). Can utilizing a computerized provider order entry (CPOE) system prevent hospital medical errors and adverse drug events? Perspectives in Health Information Management, 11(Fall): 1b Retrieved from http://perspectives.ahima.org/can-utilizing-a-computerized-provider-order-entry-cpoe-system-prevent-hospital-medical-errors-and-adverse-drug-events/#.Vpg-Q_krLIU

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.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

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 financial implications of implementing educational process versus the hospital cost of Catheter-Associated Urinary Infections (CAUTI). The Advanced Practice Nurse (APN) will demonstrate method on how to gather data, design educational tool, implement standard practice and create a committee by collaborating with other health care discipline. Effectiveness of the educational process will be evaluated through data collection. Finally, future health care delivery implications will be explored.

The root cause analysis team is made up of multiple members. It is usually led by a member of the facilities’ quality improvement program who has expertise in conducting these types of analyses. This individual is responsible for ensuring that the process focuses on systems, rather than individual’s actions. In this particular example, the team should consist of an ICU physician, the ICU nurse manager, an ICU staff nurse, pharmacist, and an emergency department physician or nurse because the medication was initiated in the emergency department (Flanders and Saint,2005,6) .

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).

This paper will review the implementation of the Electronic Medication Administration Record (eMAR) at Clayton Memorial Hospital, a 420-bed hospital, with a regional cancer center, cardiovascular services, ambulatory services and 24 physician practices in West Palm Beach, Florida. Through implementation of the eMAR, the 5 rights of medication administration are maintained (right patient, right medication, right dose, right route and right time), notifications are at the nurse’s fingertips, errors and warnings are readily available, allergy checking is automatically done, dose checking and other applicable clinical data are accessible. This paper will discuss one hospital’s journey on the path to medication safety.

The article’s topic discusses root cause analysis in regards to the evaluation of medication errors at a university hospital. According to the article, medication errors is one of the top five medical errors in the healthcare setting, which requires a root cause analysis. The focus of the article is for the healthcare agency to identify the root problem, complete a root cause analysis, and implement policy and procedures that will help to minimize or eliminate the problem. The article states that the blame for the medication error should not be placed on the individual that it happened to but on the actual process that was faulty. By doing this, it will it significantly reduce the occurrence of medication errors and promote patient safety.