The interview was conducted with a Safety Officer at the Palmetto General Hospital in Miami, FL. The discussion was centered on the current safety-enhancing practices and the analytical tools that were being implemented in the facilities at the time. Currently, Palmetto General Hospital does not have the highest ratings which concerns the Safety Officer and implies that major improvements have to be performed. The duties of a Safety Office include practitioners’ education about the topics related to patients’ safety and the development of systems and policies that reduce adverse patient outcomes. The result of this interview revealed the state of the hospital’s acquaintance with Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Serious Safety Events (SSE).
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Analysis of Errors
Root Cause Analysis
RCA is a strategy of identifying the underlying causes of problems, instead of focusing on dealing with the obvious outcomes of adverse events. While discussing the systematic processes of RCA, the Safety Officer noted that this approach is vital to determining what current problems the hospital’s units have. The previous experiences of using RCA have revealed that the staff lacked coordination which led to various problems. For example, Fluitman et al. (2016) analyze the rate of unplanned readmissions and find that patient-clinician and interprofessional collaboration were lacking in the investigated hospital. Similar to this study, the Safety Office of the Palmetto General Hospital encountered a lack of teamwork and effective communication that was not addressed by the personnel.
Failure Mode Effects Analysis
Apart from finding the hidden causes of problems, nurses should also think about the future, collecting information in order to prevent problems before they occur. The Safety Officer stated that FMEA is a valuable approach to potential concerns. This strategy can be applied to the nursing process, exploring failures to provide customers with a safe and satisfactory experience. Goodrum and Varkey (2017) argue that health care organizations have been using a reactive approach for decades, neglecting the benefits of problem prevention. During the interview, the Safety Officer agreed with this idea, commenting on the hospital’s previous responses to problems. Currently, the nursing staff is trying to implement FMEA, collecting information about failures, their possible causes, effects, and ways of detection.
Serious Safety Events
Finally, the interview contained questions about SSEs which can happen in any hospital. SSEs include practice mistakes or happenings that lead to patients’ death and serious permanent or temporary harm (Andersson, Frank, Willman, Sandman, & Hansebo, 2015). The Safety Officer noted that the facility aimed to lower the rate of SSEs and potentially eliminate any risks leading to them. According to Andersson, et al. (2015), adverse events can be prevented if patients are allowed to participate in the decision-making process. Thus, healthcare organizations should implement policies to elevate patients’ experience and educate nurses about patients’ autonomy and self-care potential. The staff of the Palmetto General Hospital is aiming to increase patient participation in the following years.
This discussion of the major safety-improving processes allows one to see how previous health care strategies can be improved with the work of a Safety Officer. RCA, FMEA, and SSE prevention are ways to address patient safety and make their experiences in the hospital satisfactory. However, they need time and participation since interprofessional collaboration lies at the basis of most efforts for change. The Safety Officer agreed that continuous work was necessary to assure that the hospital adhered to the standards of care.
Andersson, Å., Frank, C., Willman, A. M. L., Sandman, P. O., & Hansebo, G. (2015). Adverse events in nursing: A retrospective study of reports of patient and relative experiences. International Nursing Review, 62(3), 377-385.
Fluitman, K. S., van Galen, L. S., Merten, H., Rombach, S. M., Brabrand, M., Cooksley, T.,… Nanayakkara, P. W. B. (2016). Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link. European Journal of Internal Medicine, 30, 18-24.
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Goodrum, L., & Varkey, P. (2017). Prevention is better: The case of the underutilized failure mode effect analysis in patient safety. Israel Journal of Health Policy Research, 6(10), 1-2.