Reflection on learning

5

Week 5: Patient Safety and a Culture of Safety

Leonard Einstein

Shannon Hawkins

Health Informatics and Information Systems NR706

11/15/2021

Week 5: Patient Safety and a Culture of Safety

Q1: In the context of patient safety, the culture of my organization is characterized by three core concepts: learning culture, reporting culture, and a fair and just culture. Through these three elements, the organization is able to embrace safety as an important factor in achieving desirable patient outcomes and institutional objectives. Everybody in the organization is committed toward lifelong learning in order to sharpen their clinical skills and adopt new healthcare interventions that offer safer practices at the workplace. Also, the management values regular and honest reporting of incidences in the organization to ensure that everyone learns about errors made at the workplace and gets an opportunity to report unsafe work practices. This further facilitates effective investigation of errors so that their causes can be known and strategies created to prevent error reoccurrences (Tan, Pang, Siau, Foo, & Fong, 2019). Finally, the organization is a fair and just institution where justice for all stakeholders is held in high regard.

Q2: One opportunity to improve patient safety outcomes is to create a system where all patient data can be obtained from a central location. Various healthcare stakeholders including physicians, nurses, and pharmacists, among others can add information to this location and obtain relevant information as well. This allows them to know the patient’s history and make appropriate decisions when administering healthcare-related services. A strategy that can be used for the implementation of this improvement initiative is to utilize an IT-based solution that allows healthcare stakeholders to access the patient data from remote locations. This will ensure that wherever a patient goes, he/she will receive high quality care since the healthcare institution will access his/her information from a single database. This will reduce medical errors caused by poor communication between practitioners and those caused by a lack of comprehensive patient history.

Q3: The current technology used to support patient safety is the electronic health record (EHR) system. This is a real-time, patient centered record, which allows healthcare practitioners to access patient information instantly and securely (Sulmasy, López, & Horwitch, 2017). It contains all relevant treatment and medical history of a patient. This includes allergies, lab test results, immunization history, medications, and diagnoses, among others. The EHR also automates and streamlines an organization’s workflow. Additionally, it facilitates providers with evidence-based tools to make better decisions regarding their patients. However, there are potential unintended consequences of this technology. For instance, the technology may be hacked by malicious individuals and confidential and private client information leaked to unauthorized individuals (Bertagnolli, Anderson, Quina, & Piantadosi, 2020). Also, if regular updates to patient data are not done, the technology may compromise patient care. Nevertheless, there are two solutions that can address these potential consequences. First, pertinent security systems and measures should be put in place to protect the EHR from hackers and malicious individuals. This will protect the privacy and confidentiality of patients. Second, healthcare providers must stick to a strict schedule of updating patient data whenever they receive new information about their clients. This will keep the EHR up to date.

Q4: An incident in which patient safety had the potential to be compromised due to an emphasis on volume-based care was when the institution was understaffed and had to handle a large influx of patients. Since there were few healthcare practitioners, they had to do double shifts in order to handle the large number of patients. However, one nurse was fatigued due to overworking and overdosed an inpatient client as a result. This patient reacted adversely to the overdose and six doctors had to collaborate to stabilize the patient. This incident showed the problem of volume-based care, which focuses on dealing with many patients to increase the institution’s revenue at the expense of the safety of the patients.

References

Bertagnolli, M. M., Anderson, B., Quina, A., & Piantadosi, S. (2020). The electronic health record as a clinical trials tool: opportunities and challenges. Clinical Trials, 17(3), 237-242.

Sulmasy, L. S., López, A. M., & Horwitch, C. A. (2017). Ethical implications of the electronic health record: In the service of the patient. Journal of General Internal medicine, 32(8), 935-939.

Tan, K. H., Pang, N. L., Siau, C., Foo, Z., & Fong, K. Y. (2019). Building an organizational culture of patient safety. Journal of Patient Safety and Risk Management, 24(6), 253-261.