address a patient safety issue 1
MUST INCLUDE A SPECIFIC PATIENT SAFETY ISSUE THAT IS NOT IT RELATED
MUST USE HEADINGS
MUST IDENTIFY ANY EVIDENCE-BASED PRACTICE TOOLS AND TECHNIQUES THAT WOULD ELIMINATE OR REDUCE PATIENT SAFETY THREATS
SPECIFIC EXAMPLES AND ANALYSIS MUST BE GIVEN PER CRITERIA
APA FORMAT
GRADING RUBRIC MUST BE FOLLOWED TO THE LETTER
Write a 6-7 page TEXT recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue that occurred. Include an explanation of why it is important to address the issue and the role the patient safety officer will play in helping to resolve the issue.
Instructions
For the scenario you selected, 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 these headings in your paper and to address all of the bullets underneath each heading:
- Potential threat to patient safety:
- Identify the issue you selected from the simulation activity as the potential safety threat.
- Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.
- Implications of not addressing threat:
- Evaluate the risk to the organization if this issue is not addressed. In your evaluation, be sure to address all of the following:
- What does the health care safety imperative say about the issue?
- How does the health care safety imperative apply in this case?
- Which regulatory agency(ies) have oversight about the issue?
- What specifically do the regulation(s) state about the issue? For example, you might consider the Joint Commission’s national patient safety goals.
- 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?
- If the hospital fails to correct the threat, what are the potential consequences to patients, employees, and to the organization?
- Evaluate the risk to the organization if this issue is not addressed. In your evaluation, be sure to address all of the following:
- Patient safety officer’s role in effective implementation of 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.
- Recommendations to reduce patient safety threat:
- Describe your five-point plan to reduce or eliminate this patient safety threat.
- What best practice tools or techniques does your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.
- Describe your five-point plan to reduce or eliminate this patient safety threat.
In a health care professional setting, recommendations to leadership would typically not be in APA format. As a result, your paper does not need to conform to APA format and style guidelines. It does, however, 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.
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 do need to conform to APA guidelines.
ADDITIONAL RESOURCES ONLY!!!!!!!!!
The Safety Imperative
- Agency for Healthcare Research and Quality. (2017). About the national quality strategy. Retrieved from http://www.ahrq.gov/workingforquality/about/index….
- Allen, G. (2015). Infection prevention: A patient safety imperative for the perioperative setting. AORN Journal, 101(5), 508–510.
- Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759–769.
- Blouin, A. S. (2013). High reliability: Truly achieving healthcare quality and safety. Frontiers of Health Services Management, 29(3), 35–40.
- Health Care Administration Undergraduate Library Research Guide.
- Institute for Healthcare Improvement. (2018). IHI triple aim initiative. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/Pa…
- Kemper, C., Blackburn, C., Doyle, J. A., & Hyman, D. (2013). Engaging patients and families in system-level improvement: A safety imperative. Nursing Administration Quarterly, 37(3), 203–215.
- Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.
- Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., … Isaac, T. (2009). Transforming healthcare: A safety imperative [PDF]. Quality and Safety in Health Care, 18(6), 424–428.
Regulatory Agencies
- Joint Commission. (2018). 2018 national patient safety goals. Retrieved from https://www.jointcommission.org/standards_informat…
Regulatory Oversight
- Lindstrom, R. L. (2013). Dialogue between physicians, regulatory oversight agencies critical to patient safety. Ocular Surgery News, 31(17), 3.
- Wickersham, M. E., & Basey, S. (2016). Is accreditation sufficient? A case study and argument for transparency when government regulatory authority is delegated. Journal of Health and Human Services Administration, 39(2), 245–282.
Tools, Operational Considerations, and Best Practices to Address Safety Threats
- Agency for Healthcare Research and Quality. (n.d.). TeamSTEPPS: Team strategies & tools to enhance performance & patient safety. Retrieved from https://www.ahrq.gov/teamstepps/index.html
- Arabi, Y. M., Al Owais, S. M., Al-Attas, K., Alamry, A., Alzahrani, K., Baig, B., … Taher, S. (2016). Learning from defects using a comprehensive management system for incident reports in critical care. Anaesthesia & Intensive Care, 44(2), 210–220.
- Howell, A., Burns, E. M., Bouras, G., Donaldson, L. J., Athanasiou, T., & Darzi, A. (2015). Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data. PloS ONE, 10(12), 1–15.
Patient Safety Officer
- American Society of Health-System Pharmacists. (2014). ASHP statement on the role of the medication safety leader. Best Practices for Hospital & Health-System Pharmacy, pp. 207–210.
- Pratt, N. (2014). Quality officer takes on patient safety challenges. Biomedical Instrumentation & Technology, 48(4), 277–280.
- Wyatt, R. (2017). Building safe, highly reliable organizations: CQO shares words of wisdom. Biomedical Instrumentation & Technology, 51(1), 65–69.