patient safety issue

Write a 5-7 page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue.

Introduction

Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. "Quality and patient safety in health care have been on the forefront of the public's mind since the publication of the Institute of Medicine's (IOM) seminal report, 'To Err Is Human,' in 1999" (Johnson, Haskell, & Barach, 2016, p. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.

Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall.

Reference

Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016).  Case studies in patient safety. Jones & Bartlett Learning.

Preparation

To successfully complete this assessment:

· Review the following three scenarios from the Vila Health: Patient Safety simulation activity. Choose the scenario that interests you the most for further analysis in your assessment:

· Scenario 1: Patient Identification Error.

· Scenario 2: Medication Error.

· Scenario 3: HIPAA/Privacy Violation.

· Review the  Address a Patient Safety Issue Template [DOC]  which you will use to complete this assessment. This document is formatted and has space for completing all components of the assessment.

Instructions

For the scenario you selected, use the  Address a Patient Safety Issue Template [DOC]  to write a five-to-seven page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of the following in your paper and to address all of the points:

· Apply the health care safety imperative to a patient safety issue.

· Identify the issue you selected from the Vila Health simulation as the potential safety threat.

· Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.

· Identify the implications of not addressing the threat.

· Evaluate the risk to the patients, employees, and organization if patient safety threats are not addressed.

· What does the health care safety imperative say about the issue?

· How does the health care safety imperative apply in this case?

· Which regulatory agencies have oversight about the issue?

· Analyze regulatory agencies' role and impact on organizations' patient safety programs.

· What specifically do the regulations state about the issue? For example, you might consider the Joint Commission's NPSGs.

· What impact do regulatory agencies have on organizations' patient safety programs?

· How do health care organizations incorporate regulatory agencies' guidance when establishing reporting and investigation best practices?

· What are the potential consequences to the patients, employees, and organization if the hospital fails to correct the threat?

· Analyze the patient safety officer's role in implementing patient safety plans.

· Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.

· Clarify your responsibility and role as the patient safety officer in this specific instance.

· Provide one example from the literature to illustrate your points.

· Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

· Describe your five-point plan to reduce or eliminate this patient safety threat.

· What best practice tools or techniques do your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.

In a health care professional setting, recommendations to leadership would typically not be in APA format. However, your paper does need to conform to the current APA format and style guidelines. It does need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing. See the  APA Module  for more information about APA style.

Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references need to conform to APA guidelines.

Please review the Addressing a Patient Safety Issue Scoring Guide to ensure you understand the grading requirements for this assessment.

Additional Requirements

· Template: Use the  Address a Patient Safety Issue Template [DOC]  to complete this assessment.

· Length: 5–7 double-spaced pages, excluding title and reference pages.

· Font: Times New Roman, 12-point.

· APA Format: Your submission— including the body, citations, and title and references pages— needs to conform to current APA format and style guidelines. Make sure that it is clear, persuasive, organized, and well-written, without grammatical, punctuation, or spelling errors. Also, you must cite your sources according to current APA guidelines.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Analyze the quality and performance improvement activities within the health care organization.

· Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

· Competency 3: Analyze the importance of patient safety in health care.

· Apply the health care safety imperative to a patient safety issue.

· Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.

· Analyze regulatory agencies' role and impact on organizations' patient safety programs.

· Competency 4: Apply leadership strategies to quality improvement in a health care organization.

· Analyze the patient safety officer's role in implementing patient safety plans.

· Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations for health care professionals.

· Use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

· Writing adheres to APA formatting rules and APA writing style with few or minor errors.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

Collapse All

Criterion 1

Apply the health care safety imperative to a patient safety issue.

Distinguished

Applies the health care safety imperative to a patient safety issue. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Applies the health care safety imperative to a patient safety issue.

Basic

Attempts to apply the health care safety imperative to a patient safety issue; however, omissions and/or errors exist.

Non Performance

Does not attempt to apply the health care safety imperative to a patient safety issue.

Criterion 2

Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.

Distinguished

Provides a comprehensive evaluation of the risk to patients, employees, and the organization if patient safety threats are not addressed. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Evaluates the risk to patients, employees, and the organization if patient safety threats are not addressed.

Basic

Attempts to evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed; however, omissions and/or errors exist.

Non Performance

Does not attempt to evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.

Criterion 3

Analyze regulatory agencies' role and impact on organizations' patient safety programs.

Distinguished

Analyzes regulatory agencies' role and impact on organizations' patient safety programs. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Analyzes regulatory agencies' role and impact on organizations' patient safety programs.

Basic

Attempts to analyze regulatory agencies' role and impact on organizations’ patient safety programs; however, omissions and/or errors exist.

Non Performance

Does not attempt to analyze regulatory agencies' role and impact on organizations' patient safety programs.

Criterion 4

Analyze the patient safety officer's role in implementing patient safety plans.

Distinguished

Analyzes the patient safety officer's role in implementing patient safety plans. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Analyzes the patient safety officer's role in implementing patient safety plans.

Basic

Attempts to analyze the patient safety officer's role in implementing patient safety plans; however, omissions and/or errors exist.

Non Performance

Does not attempt to analyze the patient safety officer's role in implementing patient safety plans.

Criterion 5

Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

Distinguished

Recommends evidence-based best practice tools and techniques to reduce or eliminate patient safety threats. Ensures the recommendations are appropriate and comprehensive and include multiple examples, specifics, and references to the professional literature.

Proficient

Recommends evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

Basic

Attempts to recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats; however, recommendations are not always evidence-based or appropriate. Omissions and/or errors exist.

Non Performance

Does not attempt to recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

Criterion 6

Use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

Distinguished

Uses correct grammar, punctuation, and mechanics beyond what is expected of an undergraduate learner.

Proficient

Uses correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

Basic

Uses correct grammar, punctuation, and mechanics as expected of an undergraduate learner, but with some errors and lapses.

Non Performance

Does not use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

Criterion 7

Writing adheres to APA formatting rules and APA writing style with few or minor errors.

Distinguished

Writing is exemplary, exhibiting strict and nearly flawless adherence to APA formatting rules and APA writing style.

Proficient

Writing adheres to APA formatting rules and APA writing style with few or minor errors.

Basic

Writing reflects inconsistent use of APA formatting and APA writing style.

Non Performance

Writing does not adhere to APA formatting and APA writing style.

Write a 5-7 page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue.

Introduction

Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. "Quality and patient safety in health care have been on the forefront of the public's mind since the publication of the Institute of Medicine's (IOM) seminal report, 'To Err Is Human,' in 1999" (Johnson, Haskell, & Barach, 2016, p. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.

Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall.

Reference

Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016).  Case studies in patient safety. Jones & Bartlett Learning.

Preparation

To successfully complete this assessment:

· Review the following three scenarios from the Vila Health: Patient Safety simulation activity. Choose the scenario that interests you the most for further analysis in your assessment:

· Scenario 1: Patient Identification Error.

· Scenario 2: Medication Error.

· Scenario 3: HIPAA/Privacy Violation.

· Review the  Address a Patient Safety Issue Template [DOC]  which you will use to complete this assessment. This document is formatted and has space for completing all components of the assessment.

Instructions

For the scenario you selected, use the  Address a Patient Safety Issue Template [DOC]  to write a five-to-seven page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of the following in your paper and to address all of the points:

· Apply the health care safety imperative to a patient safety issue.

· Identify the issue you selected from the Vila Health simulation as the potential safety threat.

· Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.

· Identify the implications of not addressing the threat.

· Evaluate the risk to the patients, employees, and organization if patient safety threats are not addressed.

· What does the health care safety imperative say about the issue?

· How does the health care safety imperative apply in this case?

· Which regulatory agencies have oversight about the issue?

· Analyze regulatory agencies' role and impact on organizations' patient safety programs.

· What specifically do the regulations state about the issue? For example, you might consider the Joint Commission's NPSGs.

· What impact do regulatory agencies have on organizations' patient safety programs?

· How do health care organizations incorporate regulatory agencies' guidance when establishing reporting and investigation best practices?

· What are the potential consequences to the patients, employees, and organization if the hospital fails to correct the threat?

· Analyze the patient safety officer's role in implementing patient safety plans.

· Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.

· Clarify your responsibility and role as the patient safety officer in this specific instance.

· Provide one example from the literature to illustrate your points.

· Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

· Describe your five-point plan to reduce or eliminate this patient safety threat.

· What best practice tools or techniques do your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.

In a health care professional setting, recommendations to leadership would typically not be in APA format. However, your paper does need to conform to the current APA format and style guidelines. It does need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing. See the  APA Module  for more information about APA style.

Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references need to conform to APA guidelines.

Please review the Addressing a Patient Safety Issue Scoring Guide to ensure you understand the grading requirements for this assessment.

Additional Requirements

· Template: Use the  Address a Patient Safety Issue Template [DOC]  to complete this assessment.

· Length: 5–7 double-spaced pages, excluding title and reference pages.

· Font: Times New Roman, 12-point.

· APA Format: Your submission— including the body, citations, and title and references pages— needs to conform to current APA format and style guidelines. Make sure that it is clear, persuasive, organized, and well-written, without grammatical, punctuation, or spelling errors. Also, you must cite your sources according to current APA guidelines.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Analyze the quality and performance improvement activities within the health care organization.

· Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

· Competency 3: Analyze the importance of patient safety in health care.

· Apply the health care safety imperative to a patient safety issue.

· Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.

· Analyze regulatory agencies' role and impact on organizations' patient safety programs.

· Competency 4: Apply leadership strategies to quality improvement in a health care organization.

· Analyze the patient safety officer's role in implementing patient safety plans.

· Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations for health care professionals.

· Use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

· Writing adheres to APA formatting rules and APA writing style with few or minor errors.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

Collapse All

Criterion 1

Apply the health care safety imperative to a patient safety issue.

Distinguished

Applies the health care safety imperative to a patient safety issue. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Applies the health care safety imperative to a patient safety issue.

Basic

Attempts to apply the health care safety imperative to a patient safety issue; however, omissions and/or errors exist.

Non Performance

Does not attempt to apply the health care safety imperative to a patient safety issue.

Criterion 2

Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.

Distinguished

Provides a comprehensive evaluation of the risk to patients, employees, and the organization if patient safety threats are not addressed. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Evaluates the risk to patients, employees, and the organization if patient safety threats are not addressed.

Basic

Attempts to evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed; however, omissions and/or errors exist.

Non Performance

Does not attempt to evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.

Criterion 3

Analyze regulatory agencies' role and impact on organizations' patient safety programs.

Distinguished

Analyzes regulatory agencies' role and impact on organizations' patient safety programs. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Analyzes regulatory agencies' role and impact on organizations' patient safety programs.

Basic

Attempts to analyze regulatory agencies' role and impact on organizations’ patient safety programs; however, omissions and/or errors exist.

Non Performance

Does not attempt to analyze regulatory agencies' role and impact on organizations' patient safety programs.

Criterion 4

Analyze the patient safety officer's role in implementing patient safety plans.

Distinguished

Analyzes the patient safety officer's role in implementing patient safety plans. Includes multiple examples, specifics, and references to the professional literature.

Proficient

Analyzes the patient safety officer's role in implementing patient safety plans.

Basic

Attempts to analyze the patient safety officer's role in implementing patient safety plans; however, omissions and/or errors exist.

Non Performance

Does not attempt to analyze the patient safety officer's role in implementing patient safety plans.

Criterion 5

Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

Distinguished

Recommends evidence-based best practice tools and techniques to reduce or eliminate patient safety threats. Ensures the recommendations are appropriate and comprehensive and include multiple examples, specifics, and references to the professional literature.

Proficient

Recommends evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

Basic

Attempts to recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats; however, recommendations are not always evidence-based or appropriate. Omissions and/or errors exist.

Non Performance

Does not attempt to recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

Criterion 6

Use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

Distinguished

Uses correct grammar, punctuation, and mechanics beyond what is expected of an undergraduate learner.

Proficient

Uses correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

Basic

Uses correct grammar, punctuation, and mechanics as expected of an undergraduate learner, but with some errors and lapses.

Non Performance

Does not use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.

Criterion 7

Writing adheres to APA formatting rules and APA writing style with few or minor errors.

Distinguished

Writing is exemplary, exhibiting strict and nearly flawless adherence to APA formatting rules and APA writing style.

Proficient

Writing adheres to APA formatting rules and APA writing style with few or minor errors.

Basic

Writing reflects inconsistent use of APA formatting and APA writing style.

Non Performance

Writing does not adhere to APA formatting and APA writing style.