Introduction
Patient safety lies at the core of healthcare organization concerns. Any behavior by professionals that leads to adverse events has to be investigated by the hospital and outside organizations to determine whether a different approach should and could have been chosen to prevent a negative outcome for patient health. However, healthcare workers may be hesitant to talk about witnessed events due to the fear of retaliation. The Patient Safety and Quality Improvement Act addresses this issue by protecting the identity of the person who reports the problem and the information they share with organizations.
Event
While patient harm is always a poor care outcome, only some events happen due to negligence. For example, a possible event that can be reported is the lack of proper examination by a physician. In the case described by the Agency for Healthcare Research and Quality (AHRQ, 2019a), the provider sees a patient with rectal bleeding and completes a sigmoidoscopy without additional checks. Despite the patient’s persistent symptoms, the physician dismisses the problem. As the patient loses weight significantly and enters the hospital again after almost two years, it is discovered that he has colon cancer that has progressed to the liver. As a result of the investigation, the physician is found to be at fault due to negligence.
Stakeholders
The stakeholders involved in this situation are the physician, the patient, the investigating professionals, and the organization where the event happened. First, the role of the organization is to prevent such events from happening by implementing a patient safety culture (American Society for Health Care Risk Management [ASHRM], 2004). This can be achieved through a variety of approaches, including peer review, frequent training initiatives, formal checks of workers’ performance, and a focus on excellence and quality of care (ASHRM, 2007). Second, the physician responsible for the adverse event is a stakeholder, as his decision impacted patient health. His role in the adverse event is direct – his negligence and lack of attention to patient needs have led to the patient’s cancer going undiagnosed for almost two years (AHRQ, 2019a). His behavior and decision-making were some of the core elements of the problem.
Next, the patient is a stakeholder in the case, as his health was impacted by the physician’s choices. The role of the patient in such cases is to receive proper care, as he is unable to understand whether the medical professional is correct. Finally, the medical professionals investigating the event are also stakeholders, as their examination of the patient and past records determines whether the physician has acted with disregard for the patient’s well-being.
Prevention Plan
The plan for preventing such events requires the organization to review its current safety culture and improve it. Therefore, the first step towards change is to analyze the current system, its weaknesses, and strengths and create a list of potential problems that the hospital may have (ASHRM, 2019). In this case, a possible issue is the lack of training to increase the understanding and role of patient safety in proper care. Thus, the organization needs to introduce team training for healthcare workers that focuses on quality improvement, patient safety, and values (AHRQ, 2019b). Next, a possible issue is limited transparency in communication between workers and management and reporting of adverse events. The hospital needs to adopt an approach for anonymous reporting that is non-punitive, fair, and safe for workers. By using such channels, negative events can be discovered early and help mitigate patient harm (ASHRM, 2019). Proper research of such reports by the organization is also vital to separate preventable and non-preventable issues.
Conclusion
Adverse events that occur due to negligence endanger patients and harm the organization. Preventing them is a priority for the hospital, and it can be done by improving safety culture. In the investigated case, the physician’s actions are at the center of the problem, but a larger issue of a lacking reporting system and insufficient education can be found. Thus, the prevention plan should include measures to report issues anonymously and training opportunities to talk about patient safety.
References
Agency for Healthcare Research and Quality. (2019a). Adverse events, near misses, and errors. Web.
Agency for Healthcare Research and Quality. (2019b). Reporting patient safety events. Web.
American Society for Health Care Risk Management. (2004). The growing role of the patient safety officer: Implications for risk managers. Web.
American Society for Health Care Risk Management. (2007). Different roles, same goal: Risk and quality management partnering for patient safety. Web.
American Society for Health Care Risk Management. (2019). Healthcare risk management: The path forward. Web.