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Running Head: SBAR PROPOSAL FOR THE GEMBA WALK 1

SBAR PROPOSAL FOR THE GEMBA WALK 3

SBAR Proposal for the Gemba Walk

SBAR Proposal for the Gemba Walk

My Gemba walk focused on identifying areas that required changes within the Psychiatric Institute of Washington (PIW). During the walk, I discovered that PIW was at the center of probes that points accusations of abuse and negligence at the organization involving the death of a patient. I did my due diligence and discovered that the issue was caused by a very alarming distinctive and system failure at the PIW. According to reports by the “advocacy group of Disability Rights, DC,” the man passed on at the organization in 2020 April, claiming that the workforce failed to assess him properly, do CPR, and offer any possibly lifesaving actions for no less than twenty-one minutes (Howell, 2021). Additionally, the statement also specified physical and sexual abuse at the organization.

Our facility has never had such negative reports in history since we are always committed to providing the best healthcare services to our patients. I regard this as a wake-up call for our facility and the staff to work towards preserving the facility’s good name by preventing such issues from recurring. Therefore, the PIW healthcare team must formulate a corrective action plan and call the facility's leaders to increase oversight. As an organization, we are setting processes to put in place to guarantee patient safety within the facility. The first recommendation is to ensure the environment within the facility is safe, and this will require the workforce to be preemptive and intervene as fast as possible in tense situations (Shields, Stewart, & Delaney, 2018).

The second recommendation is for the organization to adopt trauma-informed care, which will help recognize and address the impacts of all types of trauma. Third, as a workforce, we should have a common understanding of how we should be treating patients through intensive training (Shields, Stewart, & Delaney, 2018). Finally, introducing policies that ensure patient-centered care is the primary focus is important in averting these issues.

References

Howell, M. (2021, June 20). Allegations of fatal missteps at DC psychiatric hospital lead to calls for change. WTOP. https://wtop.com/dc/2021/06/allegations-of-fatal-missteps-at-a-dc-psychiatric-hospital-lead-to/

Shields, M. C., Stewart, M. T., & Delaney, K. R. (2018). Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Affairs, 37(11), 1853–1861. https://doi.org/10.1377/hlthaff.2018.0718