Planning for Change: A leader's vision

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QUALITY AND SAFETY GAP ANALYSIS

Jessica Ramos, BSN, RN

Capella University

NURS-FPX6212: Health Care Quality Safety Management

Dr. Mary Ellen Cockerham

August 14, 2021

Introduction

Healthcare organizations face an increase in the number of errors committed by practitioners in the line of duty. Medical errors are events that happen to a patient due to the care provider failing to follow the planned care procedure. As a result, these events cause harm to the patient, which compromises the desired Quality of care. As a result, the reputation of the organization can be damaged and lead to litigations. In addition, errors committed by professionals can lead to the loss of jobs. In addition, these events may affect the patient adversely to the extent of causing death. Medical errors have been reported to be among the leading causes of death in the United States, although they are related to other problems such as burnout and work-related stress (Robertson & Long, 2018). This paper analyzes this problem and proposes practice changes that would help alleviate this problem.

Systemic Problems

Medical errors result when a patient is exposed to the wrong medication or by being overdosed or underdosed. Despite the challenges that these issues pose to a healthcare organization, the rate at which they have been happening is alarming, and they are considered to be among the leading causes of death in the United States among patients in a healthcare setting. As turnover rates among nursing professionals increase, the ratio of patient to nurse is also increasing. On the other hand, nurses should balance the Quality of care and at the same time maintain efficiency in care delivery. However, when nurses have a huge workload, it is likely to lead to stress and burnout, which lead to increased chances of committing medical errors. As the ratio of patients to nursing professionals continues to rise, medical errors are becoming rampant, putting the patients' lives on the line. Therefore, it is important to understand the workload nurses are supposed to deliver and how this leads to increased medical errors (Robertson & Long, 2018). Committing medical errors within a medical unit is so severe that in addition to ruining an organization’s reputation, it leads to legal consequences that affect the organization's ability to continue operating, affecting the financial abilities of the organization as cases of reimbursements increase.

Proposed Practice Changes

As healthcare organizations face an unprecedented increase in medical errors, they must implement systems that would help them identify possible errors and thus reduce related events, which compromise the Quality of care. Some of the proposed changes in care delivery would be adopting an electronic health record system that would help the nurses monitor the medication being administered to confirm it is the right one before it is administered to the patient. Besides, it is important to cross-check the medication before it is administered to the patient. These are some practical approaches that can be used to prevent errors and guarantee quality care to patients. Electronic health record has reduced medical and communication errors and empowered the patients to be an active participant in the process such that they can ask any questions regarding their medication, which promotes better outcomes (Gupta, 2020). There is also a need to implement communication training programs that help improve communication between nurses and physicians, thus promote understanding.

The current healthcare systems have not fully adopted computerized systems to monitor patient treatment schedules, which create room for errors. However, suppose this organization can increase their dependence on computerized systems such as electronic health records. In that case, the care provider will perform a background check to ascertain the treatment required before medication is administered. This ensures patient safety and Quality of care is maintained (Gupta, 2020). It is also important that nursing practice be monitored with practitioners after the electronic health record has been used to ensure optimum efficiency. In addition, any information that has been forgotten is retrieved before medication is administered and ensures the reliability of the information, promoting safer and high-quality care to patients.

Priority Proposed Changes

The primary focus of the proposed changes should be to improve the Quality of care and safety of the patient. This will ensure that adverse events that may affect the patient negatively are eliminated. Electronic health records play an important role in ensuring errors are eliminated and the follow up of the right procedures in care delivery, thus promoting a safety-focused care delivery. The double-check of the treatment procedure and medication before administration to the patient ensures possible errors are detected on time. In addition, the nurse will evaluate the proposed medication based on their knowledge and collaborate with their coworkers to ensure it is the right one. Nurses are supposed to use their prior knowledge about medication and inquire about the correct medication when they are unsure of the proper medication to be administered in a situation (Granada, 2019). This will ensure all events that may compromise patient safety are eliminated.

How the culture of Quality will be fostered by Proposed Change

The proposed changes will promote better quality care delivery to patients. The healthcare organization will focus on monitoring the Quality of care delivered by evaluating activities and making improvements where there are deficiencies in the Quality of medication for the patients. The organization will also assess the outcome of each healthcare decision made and focus on those that lead to the best outcomes for the patients. Technology will be a priority strategy for healthcare organizations to reduce medical errors and maintain timely medical administrations, which promote overall Quality of care.

How Organizational Hierarchy Impacts Quality and Safety Outcomes

On the other hand, organizational hierarchies can compromise the effectiveness of care delivery, especially in an organization with communication barriers. This is likely to impact care delivery when such barriers prevent the available personnel from executing their duties waiting for directions from their seniors. This negatively timely delivery of patient care leads to complications as patients' conditions worsen and their safety is compromised. In avoiding such adverse events, communication channels should be improved to ensure all the players agree and are aligned to the organization's goals (Merlino, 2017). In addition, the organization should ensure that it implements a culture of change to avoid institutional rigidities, which may reduce resistance to change.

Justification of Proposed Changes

Quality improvement strategies are central to improving the Quality of care and promoting patient safety. When all the organization stakeholders adopt the proposed changes, the quality goals are achieved, which leads to overall organizational success. In addition, an organization whose primary goal is to promote patient safety will implement any changes that promote the organization's overall success.

Conclusion

Healthcare organizations are faced with adverse events that affect the Quality of care. Medical errors compromise patient safety and continue to haunt many organizations. However, eliminating institutional barriers to change can help implement strategies that will eliminate medical errors, promote patient safety and improve Quality of care. Communication is key to ensure an integrative care system that promotes collaboration, timely detection of errors, and overall evidence-based care that achieves the goal of quality care and improves positive patient outcomes.

References

Granada, L. (2019). Nursing Education Workflows in EHR Training (Doctoral dissertation, Walden University). https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=8036&context=dissertations

Gupta, S. (2020). SafeStart Medical: An Innovative HIT Solution to Never Events (WSPE). https://digitalcommons.imsa.edu/intern_reports_2020/8/

Merlino, J. (2017). Communication: A critical healthcare competency. Patient Saf. Qual. HealthCare. https://www.psqh.com/analysis/communication-critical-healthcare-competency/

Robertson, J. J., & Long, B. (2018). Suffering in silence: medical error and its impact on health care providers. The Journal of emergency medicine, 54(4), 402-409. DOI: 10.1016/j.jemermed.2017.12.001