Select one of the three incidents from the Vila Health: Patient Safety simulation you completed in Assessment 1. These are common incidents you are likely to encounter in the health care field. These included a patient identification error, a medication error, and a HIPAA/privacy violation. You may select one of the incidents you worked with in the previous assessments or select another one. Pick one that holds the most interest for you. The incident I previously selected was a medication error. In this incident two patients with similar names and birthdates B.moore( dob:8/11/05) and B.R.Moore (dob:11/8/05) where on the same floor with rooms directly across from each other. B.moore was given the wrong medication that was intended for B.R.Moore. Not only was a medication error made but a patient identification error was made which led to the medication error and B. Moore was given the wrong medication. The hospital staff stated that despite being short staffed precautions were implemented to ensure the safety of both patients. Different nurses were assigned to each patient and all shifts were made aware by leaving detailed notes in each chart. Despite all of this, a medication error still occurred. The Risk Manager became aware of the medication error and began an investigation, which involved speaking with Patient Safety Officer to advise of her the situation.
Consider these analysis questions once you have selected the incident on which you will focus:
What information do you possess about the issue? (Note: You may not be able to answer all of these questions; just include the information you know.) Consider:
Who was involved?
During what process (clinical, communication, operational) did the issue occur?
When did the issue occur? During a particular shift? On a particular day? During peak hours? Under certain clinical circumstances?
Where did the issue occur?
What additional data about the incident would you like to collect and analyze?
Which best practices may not have been adhered to that may have contributed to the issue?
Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an organization-wide basis. Please make sure to include all of the following headings and answer all of the questions underneath each heading.
How would you summarize the key elements of the incident that occurred?
What is your goal in addressing the issue?
Which two to three key items will be your focus? For example, you may elect to focus on nursing staffing levels if being short staffed in nursing is contributing to compromises to patient safety.
IHI Triple Aim
What is the IHI Triple AIM?
How does the IHI Triple Aim apply to this specific incident?
What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?
What is culture?
Why is culture a critical organizational priority for safety and quality?
Based on the knowledge you have about the selected issue, what do you know about the existing organizational culture?
What are some of the evidence-based strategies you are considering you could employ to cultivate a culture of safety?
Which key departments need to be directly involved with the corrective action process?
What is your rationale for selecting these departments? For example, you may want to involve nursing because many of errors involve nurses and obtaining their buy-in is critical to achieving the organizational priority.
Which specific senior leader, front line staff member, and clinical expert will you include in your action plan and hold accountable for implementation?
What are the implications of not engaging with all departments toward making safety and quality top of mind?
How might you involve other departments in addressing the specific issue and the cultural issue?
Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind throughout the organization? Examples for you to consider include the chief nursing officer, the chief medical officer, the patient safety officer, et cetera.
What role do you expect these leaders to play in addressing the specific issue and the issue of culture?
What best practices would you employ to enlist their aid in the improvement effort?
What role does the organization’s governing board have in terms of quality and safety in the organization?
How could you enlist the governing board’s aid in your improvement initiative?
What additional information could you provide them to increase their involvement in the organization’s safety and quality improvement efforts?
Leadership Action Plan
What are three evidence-based actions you recommend that would help to solve the incident that arose?
What are three evidence-based best practices you recommend to address the issue on an organizational level?
How will you summarize your analysis of the incident and your leadership action plan?
Remember that health care is an evidence-based field. You will need to cite a minimum of two credible references to support your analysis and action planning process.
In addition, in the health care field, your analysis and action plan would not typically be written in APA format. Do ensure that it is clear, persuasive, concise, organized, and without errors in grammar, punctuation, and spelling. Do provide citations and title and reference pages in APA format. Other leaders in your organization are going to want to know what sources you relied on to prepare your analysis and action plan.