Asses4

1

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Analyze a Current Health Care Problem or Issue

Learner’s Name

Capella University

NHS4000: Developing a Health Care Perspective

Instructor Name

August, 2020

2

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Analyze a Current Health Care Problem or Issue

Patient safety, as discussed in the previous assessment, is an important element of quality

health care. This assessment will expand upon patient safety issues that occur when patients are

exposed to inadvertent harm or injury while receiving medical care. Health care organizations

should maintain and develop a safety culture to prevent patient safety issues. Patient safety

culture is defined as a system that promotes safety by shared organizational values of what is

important and beliefs about how things work. It also encompasses how these values and beliefs

interact with the work unit, organizational structures, and systems to produce behavioral norms

(Ulrich & Kear, 2014). As such, care should be taken to improve the infrastructure of health care

organizations. Improving patient safety should be discussed and addressed by every individual

associated with public health care.

Elements of the Problem/Issue

Research shows that while getting treated at health care organizations, patients might be

at risk of experiencing the harm or injuries associated with medical care. The most likely causes

of patient safety issues are preventable adverse events, which are adverse events attributable to

error. These errors can be classified as diagnostic errors, contextual errors, and communication

errors (Ulrich & Kear, 2014).

Diagnostic errors take place when health care professionals provide a wrong or delayed

diagnosis or no diagnosis at all (James, 2013). An example of a wrong diagnosis is a health care

professional diagnosing a patient with gastric troubles when the patient is actually experiencing a

heart attack. An example of a delayed diagnosis is a patient not being notified of an abnormal

chest X-ray, thereby delaying diagnosis of a serious medical condition. An example of a missed

diagnosis is a patient not being diagnosed with heart failure despite warning symptoms.

3

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Contextual errors occur when health care professionals fail to consider their patients’

personal or psychological limitations while planning appropriate care for them. An example is a

health care professional’s failure to recognize that basic follow-up discharge instructions may not

be understood by patients with cognitive disabilities (James, 2013). It is important for health care

professionals to be aware of their patients’ mental and physical abilities before they formulate a

plan of care.

Communication errors occur when there is miscommunication or lack of communication

between health care professionals and patients (James, 2013). They can cause severe harm to

patients. An example of this is a nurse failing to tell a surgeon that a patient experienced

abdominal pain and had a drop in red blood cell count after an operation, resulting in the death of

the patient due to severe internal bleeding. Limited health care knowledge; language barriers;

and auditory, visual, and speech disabilities could also lead to communication errors and cause

safety issues.

Analysis

As a medical transcriptionist, it is important for me to be aware of potential transcription

errors and privacy standards, which affect patient safety. Errors like these pose dangerous risks;

therefore, it is necessary to have an overall quality evaluation of the transcribed documents.

Also, I must ensure that serious difficulties in transcription resulting from poor-quality voice

files are reported immediately to the manager, who will then convey this to the health care

professionals involved in the process. This will help ensure that patient safety is not

compromised.

Context for Patient Safety Issues

With the advancement of medical technology, health care processes have become

extremely complex. Health care professionals are required to stay up to date with a lot of new

4

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

knowledge and innovations obtained from research. This often overburdens them as there is a

need to apply the learning from research in their practice. Also, at the individual level, there is a

dearth of well-balanced continuing education programs, which has resulted in a lack of attention

to patient safety among health care professionals. At the system level, organizations fail to

deliver optimum health care as a result of being understaffed, an inability to provide appropriate

technology, and ineffective execution of patient care transfer (James, 2013). Overcrowding and

understaffing delays initiation of treatment and puts critically ill patients at significant risk. All

of these factors contribute to a rise in patient safety issues.

Populations Affected by Patient Safety Issues

Patients with a psychiatric history are also a vulnerable group of people who face patient

safety issues because their psychiatric records are often combined with their current symptoms.

Patients with a documented history of psychiatric illness may avoid seeking health care services as

they feel that their care will be based on their past record of illnesses and not their present needs.

Therefore, psychotherapists should implement measures such that their psychiatric data is concealed

from their medical records before it is shared with the third party, which helps protect patients’

confidentiality (Shenoy & Appel, 2017).

Considering Options

Patient safety in hospitals can be achieved by creating a culture of safety that involves

effective communication, correct managerial leadership styles, and the use of Electronic Health

Records (EHRs). Effective communication while passing patient-specific information from one

health care professional to another is essential in ensuring continuous and safe patient care.

Training the team could likely improve consistent successful communication and help prevent

errors. Standardizing critical content that needs to be communicated by the initial health care

professional ensures safe transfer of care (Farmer, 2016).

5

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

It is essential for leadership teams to adopt organizational strategies that would improve

patient safety and transform their organizations into reliable systems for enhanced patient

satisfaction. They should set strategic safety goals, which could include adhering to standards of

health, assessing quality, using patient satisfaction reviews, and analyzing adverse event reports

to determine improvement in safety issues (Parand et al., 2014).

An EHR is another potential solution to prevent patient safety issues. It is a digital record

of a patient’s medical information that includes history, physical examination, investigations, and

treatment (Ozair et al., 2015). It helps manage multiple processes in the complex health care

system and prevents errors. EHRs utilize less storage space compared to paper documentation

and allow an infinite number of records to be stored. In addition to being cost-effective and

preventing a loss of records, EHRs help conduct research activities and provide quick data

transfer (Ozair et al., 2015).

Solution

In health care, because transmission of information takes place among different people

and electronic devices, there is a high likelihood of errors occurring. For example, transcription

errors (which occur due to poor audio quality or the lack of a quality evaluation process) can be

prevented by using recording equipment with good sound quality and by maintaining

proofreading and quality checks. However, integrating transcription processes with the HER

system helps prevent errors, helps access the required information faster, and allows health care

professionals to take accurate decisions about patients’ care.

Implementation

An EHR is an important mechanism for improving patient safety. Its advancement has

made it a viable option to prevent medical errors. However, the use of EHRs has certain ethical

implications such as security violation, data inaccuracies, lack of privacy and confidentiality, and

6

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

challenges during system implementation. Security violation takes place when patients’

confidential health information is accessible to others without their permission. To avoid security

violation, data should not only be password protected but also encrypted to restrict access to

unauthorized individuals. Firewalls and antivirus software should be used to protect data (Ozair

et al., 2015).

Though EHRs improve patient safety by reducing medical errors, data inaccuracies are

increasing. Loss of data during data transfer leads to inaccuracies that affect decision-making

related to patient care. A problem of concern related to data inaccuracy is medical identity theft,

which leads to incorrect information being filed into a person’s medical record, which in turn

leads to insurance fraud and wrong billing (Ozair et al., 2015).

In health care, information that is shared during physician–patient interactions should be

kept confidential and should be made inaccessible to unauthorized individuals. Enabling role-

based access controls based on user credentials will restrict access to the EHR system to

authorized users. The user should also be made aware that he or she is responsible for any

information that he or she misuses (Ozair et al., 2015).

As EHR is a complex software, there is a high likelihood that software failure may result

in inaccurate recordings of patients’ data. Therefore, EHR system implementation may have

ethical implications due to the violation of data integrity (Ozair et al., 2015). EHRs can safeguard

patient confidentiality by using various methods that prevent security breaches. In addition to

this, creating reminders that ask for a confirmation before accessing confidential information can

help protect data. A nesting system could be developed, which would allow, for example, a

health care professional from a specific specialty clinic to access patient records by signing into

the specialty domain (Shenoy & Appel, 2017). These methods will enable the safe and efficient

use of EHRs and ensure patient safety.

7

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Conclusion

Patient safety involves preventing the risk of harm or injuries to patients by establishing a

safety culture and providing high-quality medical care. Health care organizations must

understand patient safety issues and find solutions for these issues by designing systems that

prevent errors from occurring. Potential solutions include effective communication, changes in

leadership style, and the use of EHRs. The ethical implications of these solutions should be

considered before implementing them in a health care setting. It is also important that health care

professionals undergo continuous education and effective training, provide appropriate medical

care, prevent errors, and follow safety practices to improve clinical outcomes.

8

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

References

Farmer, B. M. (2016). Patient safety in the emergency department. Emergency Medicine, 48(9),

396–404. https://mdedge.com/emed-journal/article/113659/trauma/patient-safety-

emergency-department

Flood, B. (2017). Safety of people with intellectual disabilities in hospital. What can the hospital

pharmacist do to improve quality of care? Pharmacy, 5(3).

https://ncbi.nlm.nih.gov/pmc/articles/PMC5622356/

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital

care. Journal of Patient Safety, 9(3), 122–128.

http://dx.doi.org/10.1097/PTS.0b013e3182948a69

Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health

records: A general overview. Perspectives in Clinical Research, 6(2), 73–76.

http://dx.doi.org/10.4103/2229-3485.153997

Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality

and patient safety: A systematic review. BMJ Open, 4(9).

http://dx.doi.org/10.1136/bmjopen-2014-005055

Shenoy, A., & Appel, J. M. (2017, April). Safeguarding confidentiality in electronic health

records. Cambridge Quarterly of Healthcare Ethics, 26(2), 337–341. https://search-

proquest-com.library.capella.edu/docview/1882434628?pq-

origsite=summon&https://library.capella.edu/login?url=accountid=27965

Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent

health care delivery. Nephrology Nursing Journal, 41(5), 447–456, 505. https://search-

proquest-

9

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

com.library.capella.edu/docview/1617932572/fulltextPDF/1486CC30B3624B3CPQ/1?ac

countid=27965

1

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Analyze a Current Health Care Problem or Issue

Learner’s Name

Capella University

NHS4000: Developing a Health Care Perspective

Instructor Name

August, 2020

2

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Analyze a Current Health Care Problem or Issue

Patient safety, as discussed in the previous assessment, is an important element of quality

health care. This assessment will expand upon patient safety issues that occur when patients are

exposed to inadvertent harm or injury while receiving medical care. Health care organizations

should maintain and develop a safety culture to prevent patient safety issues. Patient safety

culture is defined as a system that promotes safety by shared organizational values of what is

important and beliefs about how things work. It also encompasses how these values and beliefs

interact with the work unit, organizational structures, and systems to produce behavioral norms

(Ulrich & Kear, 2014). As such, care should be taken to improve the infrastructure of health care

organizations. Improving patient safety should be discussed and addressed by every individual

associated with public health care.

Elements of the Problem/Issue

Research shows that while getting treated at health care organizations, patients might be

at risk of experiencing the harm or injuries associated with medical care. The most likely causes

of patient safety issues are preventable adverse events, which are adverse events attributable to

error. These errors can be classified as diagnostic errors, contextual errors, and communication

errors (Ulrich & Kear, 2014).

Diagnostic errors take place when health care professionals provide a wrong or delayed

diagnosis or no diagnosis at all (James, 2013). An example of a wrong diagnosis is a health care

professional diagnosing a patient with gastric troubles when the patient is actually experiencing a

heart attack. An example of a delayed diagnosis is a patient not being notified of an abnormal

chest X-ray, thereby delaying diagnosis of a serious medical condition. An example of a missed

diagnosis is a patient not being diagnosed with heart failure despite warning symptoms.

3

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Contextual errors occur when health care professionals fail to consider their patients’

personal or psychological limitations while planning appropriate care for them. An example is a

health care professional’s failure to recognize that basic follow-up discharge instructions may not

be understood by patients with cognitive disabilities (James, 2013). It is important for health care

professionals to be aware of their patients’ mental and physical abilities before they formulate a

plan of care.

Communication errors occur when there is miscommunication or lack of communication

between health care professionals and patients (James, 2013). They can cause severe harm to

patients. An example of this is a nurse failing to tell a surgeon that a patient experienced

abdominal pain and had a drop in red blood cell count after an operation, resulting in the death of

the patient due to severe internal bleeding. Limited health care knowledge; language barriers;

and auditory, visual, and speech disabilities could also lead to communication errors and cause

safety issues.

Analysis

As a medical transcriptionist, it is important for me to be aware of potential transcription

errors and privacy standards, which affect patient safety. Errors like these pose dangerous risks;

therefore, it is necessary to have an overall quality evaluation of the transcribed documents.

Also, I must ensure that serious difficulties in transcription resulting from poor-quality voice

files are reported immediately to the manager, who will then convey this to the health care

professionals involved in the process. This will help ensure that patient safety is not

compromised.

Context for Patient Safety Issues

With the advancement of medical technology, health care processes have become

extremely complex. Health care professionals are required to stay up to date with a lot of new

4

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

knowledge and innovations obtained from research. This often overburdens them as there is a

need to apply the learning from research in their practice. Also, at the individual level, there is a

dearth of well-balanced continuing education programs, which has resulted in a lack of attention

to patient safety among health care professionals. At the system level, organizations fail to

deliver optimum health care as a result of being understaffed, an inability to provide appropriate

technology, and ineffective execution of patient care transfer (James, 2013). Overcrowding and

understaffing delays initiation of treatment and puts critically ill patients at significant risk. All

of these factors contribute to a rise in patient safety issues.

Populations Affected by Patient Safety Issues

Patients with a psychiatric history are also a vulnerable group of people who face patient

safety issues because their psychiatric records are often combined with their current symptoms.

Patients with a documented history of psychiatric illness may avoid seeking health care services as

they feel that their care will be based on their past record of illnesses and not their present needs.

Therefore, psychotherapists should implement measures such that their psychiatric data is concealed

from their medical records before it is shared with the third party, which helps protect patients’

confidentiality (Shenoy & Appel, 2017).

Considering Options

Patient safety in hospitals can be achieved by creating a culture of safety that involves

effective communication, correct managerial leadership styles, and the use of Electronic Health

Records (EHRs). Effective communication while passing patient-specific information from one

health care professional to another is essential in ensuring continuous and safe patient care.

Training the team could likely improve consistent successful communication and help prevent

errors. Standardizing critical content that needs to be communicated by the initial health care

professional ensures safe transfer of care (Farmer, 2016).

5

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

It is essential for leadership teams to adopt organizational strategies that would improve

patient safety and transform their organizations into reliable systems for enhanced patient

satisfaction. They should set strategic safety goals, which could include adhering to standards of

health, assessing quality, using patient satisfaction reviews, and analyzing adverse event reports

to determine improvement in safety issues (Parand et al., 2014).

An EHR is another potential solution to prevent patient safety issues. It is a digital record

of a patient’s medical information that includes history, physical examination, investigations, and

treatment (Ozair et al., 2015). It helps manage multiple processes in the complex health care

system and prevents errors. EHRs utilize less storage space compared to paper documentation

and allow an infinite number of records to be stored. In addition to being cost-effective and

preventing a loss of records, EHRs help conduct research activities and provide quick data

transfer (Ozair et al., 2015).

Solution

In health care, because transmission of information takes place among different people

and electronic devices, there is a high likelihood of errors occurring. For example, transcription

errors (which occur due to poor audio quality or the lack of a quality evaluation process) can be

prevented by using recording equipment with good sound quality and by maintaining

proofreading and quality checks. However, integrating transcription processes with the HER

system helps prevent errors, helps access the required information faster, and allows health care

professionals to take accurate decisions about patients’ care.

Implementation

An EHR is an important mechanism for improving patient safety. Its advancement has

made it a viable option to prevent medical errors. However, the use of EHRs has certain ethical

implications such as security violation, data inaccuracies, lack of privacy and confidentiality, and

6

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

challenges during system implementation. Security violation takes place when patients’

confidential health information is accessible to others without their permission. To avoid security

violation, data should not only be password protected but also encrypted to restrict access to

unauthorized individuals. Firewalls and antivirus software should be used to protect data (Ozair

et al., 2015).

Though EHRs improve patient safety by reducing medical errors, data inaccuracies are

increasing. Loss of data during data transfer leads to inaccuracies that affect decision-making

related to patient care. A problem of concern related to data inaccuracy is medical identity theft,

which leads to incorrect information being filed into a person’s medical record, which in turn

leads to insurance fraud and wrong billing (Ozair et al., 2015).

In health care, information that is shared during physician–patient interactions should be

kept confidential and should be made inaccessible to unauthorized individuals. Enabling role-

based access controls based on user credentials will restrict access to the EHR system to

authorized users. The user should also be made aware that he or she is responsible for any

information that he or she misuses (Ozair et al., 2015).

As EHR is a complex software, there is a high likelihood that software failure may result

in inaccurate recordings of patients’ data. Therefore, EHR system implementation may have

ethical implications due to the violation of data integrity (Ozair et al., 2015). EHRs can safeguard

patient confidentiality by using various methods that prevent security breaches. In addition to

this, creating reminders that ask for a confirmation before accessing confidential information can

help protect data. A nesting system could be developed, which would allow, for example, a

health care professional from a specific specialty clinic to access patient records by signing into

the specialty domain (Shenoy & Appel, 2017). These methods will enable the safe and efficient

use of EHRs and ensure patient safety.

7

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

Conclusion

Patient safety involves preventing the risk of harm or injuries to patients by establishing a

safety culture and providing high-quality medical care. Health care organizations must

understand patient safety issues and find solutions for these issues by designing systems that

prevent errors from occurring. Potential solutions include effective communication, changes in

leadership style, and the use of EHRs. The ethical implications of these solutions should be

considered before implementing them in a health care setting. It is also important that health care

professionals undergo continuous education and effective training, provide appropriate medical

care, prevent errors, and follow safety practices to improve clinical outcomes.

8

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

References

Farmer, B. M. (2016). Patient safety in the emergency department. Emergency Medicine, 48(9),

396–404. https://mdedge.com/emed-journal/article/113659/trauma/patient-safety-

emergency-department

Flood, B. (2017). Safety of people with intellectual disabilities in hospital. What can the hospital

pharmacist do to improve quality of care? Pharmacy, 5(3).

https://ncbi.nlm.nih.gov/pmc/articles/PMC5622356/

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital

care. Journal of Patient Safety, 9(3), 122–128.

http://dx.doi.org/10.1097/PTS.0b013e3182948a69

Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health

records: A general overview. Perspectives in Clinical Research, 6(2), 73–76.

http://dx.doi.org/10.4103/2229-3485.153997

Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality

and patient safety: A systematic review. BMJ Open, 4(9).

http://dx.doi.org/10.1136/bmjopen-2014-005055

Shenoy, A., & Appel, J. M. (2017, April). Safeguarding confidentiality in electronic health

records. Cambridge Quarterly of Healthcare Ethics, 26(2), 337–341. https://search-

proquest-com.library.capella.edu/docview/1882434628?pq-

origsite=summon&https://library.capella.edu/login?url=accountid=27965

Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent

health care delivery. Nephrology Nursing Journal, 41(5), 447–456, 505. https://search-

proquest-

9

Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

com.library.capella.edu/docview/1617932572/fulltextPDF/1486CC30B3624B3CPQ/1?ac

countid=27965