The Patient Safety and Quality Improvement Act designates a voluntary reporting system to expand the available data to evaluate and address patient safety and health care quality issues. This act authorizes the Department of Health to charge civil fines for patient information privacy violations. Furthermore, it provides federal privileges and privacy protections for patient safety information to facilitate reporting and investigation of medical errors. By this law, the Agency for Healthcare Research and Quality is qualified to compile a list of patient safety organizations which are outside experts to analyze patient safety information. This paper will analyze a sample case of an event that has occurred under one of the three reportable categories.
Reportable Events Review
The concept of patient safety is not new these days – it is one of the basic principles of medicine. The Commission on Accreditation of Healthcare and medical professional groups have addressed patient safety of care in inspection requirements, clinical guidelines, articles, and research studies (Roberts-Turner & Shah, 2021). However, patient safety and care have not received as much attention in the medical profession.
Reportable events in patient safety are those that should never have happened in the hospital and should be reported immediately. Such events fall into three basic categories: those that did not harm the patient, those that affected the patient, and those that harmed the patient’s health. In any situation, incidents must be identified and thoroughly investigated to prevent the possibility of their occurrence in the future. After all, even the incident that did not affect the patient could cause serious harm to the patient’s health if repeated in other circumstances.
Reporting is crucial to recognising and assessing errors to determine root causes which lead to process improvement. It is essential to reduce risk and prevent any harm that can be done to the patient. All team members must detect and report any case, like medication error, near miss, hazardous condition, process failure, injuries involving patients, visitors and staff or a sentinel event.
Patient Safety Event Example
Medication distribution errors are at the top of the list of all incidents (Wu & Busch, 2019). The patient safety incident from this specific group is taken and the exact circumstances of what happened are as follows. A few minutes before the shift at the hospital ended in the evening, a nurse mixed up patients’ medical records or locations, and medications prescribed to patient A were administered to patient B. In this case, the medications were not harmful to the life or health of the patient to whom they were administered. In such a case, the incident is undoubtedly reportable but belongs to the no-harm group. However, this case is double or involves a secondary incident – patient A was deprived of the necessary amount of medication and received it later with a delay (Campione & Famolare, 2018). There was also no effect on patient A’s health in this case.
Also, this patient’s medical records were marked for medication dispensing, and the next staff member on the shift discovered the incident only when the patient complained about the lack of medication. When the cause was investigated, the nurse responsible for the incident was immediately contacted. Possible reasons could include her fatigue at the end of a long shift or inattention due to a longing to finish work as soon as possible (Wu & Busch, 2019). As a result, there was no harm to patients’ health, so this situation can be called a “near miss”, but the fact of the incident itself is crucial. What follows is a brief analysis of the stakeholders in this situation.
Stakeholder Analysis of the Safety Event
In the process of improving patient safety in the medical field, stakeholders may include the patient, medical establishment staff and managers, sponsors (equipment manufacturers, laboratories, external research), and government regulatory agencies (e.g., Food and Drug Administration). The stakeholder analysis of these parties determines their motivation, resources, and the final result they need.
In a particular case, the state and health organizations’ shared interest in increasing the risk management level can be disregarded. In the order of the hierarchy, the first stakeholder is the hospital management. Its motivation is to provide the necessary care to patients. The resources used are funding, medical devices and facilities, and human resources (Campione & Famolare, 2018). One of the final goals (besides financial and other development) is the satisfaction of each patient with the service provided. It is this goal that is compromised by the incident that occurred.
The next stakeholder is the person directly responsible for the incident, the nurse. The employee’s primary motivation is, first and foremost, decent pay and a stable workplace (Campione & Famolare, 2018). Using their time, knowledge and work as resources, the medical employee achieves the goal of personal and professional development by helping people, which helps to raise earnings and increase motivation. Resources can also include all the necessary medical supplies and the ability to use them correctly, which was violated in this case. It is in the employee’s interest to do their job as well as possible, as such an incident could lead to a reprimand, a fine, or more severe consequences.
The ultimate and, in some ways, the primary stakeholder is the patient. In this case, two patients – the one who received the unnecessary treatment and the one whose medication schedule was violated. The motivation of each of them is to receive the necessary medical care. Whether in outpatient or inpatient care, the person trusts the medical staff and expects them to provide timely and correct assistance (Wu & Busch, 2019). They both had the resources and the opportunity to sue in the case described because the circumstances could have influenced their ultimate goals of making a recovery as complete, rapid and financially profitable as possible.
Patient Safety Issue Prevention Strategy
In order to ensure such an incident will not happen again, several changes ought to be made to the evening and night care at the hospital. First and foremost, training on risk management and performance improvement should undoubtedly be provided to all staff responsible for distributing and dispensing medications. Increase the number of staff responsible for administering medications so that there are at least two of them at any given time and they can check on each other (Wu & Busch, 2019). Revise the work schedule of the employee who made this error – perhaps the quantity of overtime is reducing productivity. Also, some treatment facilities use additional labelling of medical files, patient data, and their respective locations using different colours or barcodes. All of these methods should help avoid similar errors in the future.
Employee Notification via the E-mail
Email subject line: Medication mix-up and other errors prevention
Dear colleagues,
The plan to prevent medical errors is going to be implemented. Please follow all its recommendations below. Shift supervisors will oversee employees and are responsible for plan compliance.
- Correctly identify patients by confirming their identity.
- Determinate possible hazards and risks to patient safety.
- Enhance communication with the patient.
- Always wash hands and equipment, and utilize post-operative antibiotics.
- Pause before any essential action to double-check.
- In case of surgery, ensure the correct surgery is performed on the correct part of the body.
- Double-check the medications’ labels.
Supplementary risk management and patient security training will be provided to all department staff members. The training schedule will be provided later in the thread. Attendance by all branch employees is mandatory.
Furthermore, an additional marking system will be developed at the training, staff opinion is welcomed and will be taken into consideration.
Upon completion of the training, additional staff evaluations will be performed. The evening shift supervisor is responsible for these processes.
Please, remember – the security of the patient is the highest priority.
References
Campione, J., & Famolaro, T. (2018). Promising practices for improving hospital patient safety culture. The Joint Commission Journal on Quality and Patient Safety, 44(1), 25-32.
Roberts-Turner, R., & Shah, R. K. (2021). Pocket guide to quality improvement in healthcare. Springer Nature.
Wu, A. W., & Busch, I. M. (2019). Patient safety: a new basic science for professional education. GMS journal for medical education, 36(2), 21.