Patient Safety Essay

The Joint Commission introduced the National Patient Safety Goals to address patient safety issues within health care organizations. The National Patient Safety Goals (NPSGs) were established in 2002 in order to assist the institutions that are accredited address issues relating to patient safety. Their implementation started in January 2003, a process that has undergone review to the latest year 2016 version which introduced the second level of implementation of clinical alarms utilization to promote patient safety (JCI, 2016).

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis.

Patient safety is of major concern in healthcare settings due to the preventable nature of events that sometimes lead to serious injury, and even death, for patients. This was catapulted to the forefront of healthcare delivery in 1999 when the Institute of Medicine wrote a scathing report; To Err is Human: Building a Safer Health System, that highlighted "the lack of safety for patients in healthcare organizations" (Ulrich and Kear 2014). The National Patient Safety

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

Taylor, C. Littis, C., Lynn, P., & LeMone, P. (2015). Urinary Elimination. In S. Dickinson (Ed.),

Patient safety has become a major concern in the healthcare sector because of the prevalence of medical errors. Patient safety has even stood out as its own ideal discipline and it encompasses certain areas of healthcare service provision such as reporting, analysis and prevention of medical errors (because of the upsurge of medical errors across the globe). Initially, medical errors were not considered a big issue in medical circles until there was an increased trend of medical errors across the globe which resulted into adverse medical events and a high number of patient deaths. This trend prompted the World Health Organization (WHO) to carry out an assessment of the impact of medical errors across the globe and established that at least 1 in every 10 patient across the globe is normally affected by medical errors (World Health Organization 2008).

Patient safety should be the top priorty of every hospital and medical professional. Unfortunately it seems that priority gets lost sometimes in the business of health care. For example, the national death rate from a knee replacement surgery is about 1 in 1000. Patients that have that surgery done at a hospital that does not regularly perform it are 3 times more likely to die. However a recent story on National Public Radio highlighted some positive steps a few of the countries leading teaching hospitals are taking to prevent unnecessary risks to the safety of their patients.

The home health agency ordered a registered nurse the admission of a new diabetic patient at home, the process is called Start of Care Assessment (SOC); the doctor ordered the nurse to administer 1000 mcg of Vitamin B12 monthly, intramuscular. The patient has a medical history of cardiovascular disease, obesity, right leg amputation, incontinence and anemia. At the admission, the nurse noted a Stage I pressure ulcer on the sacral area, a Stage I pressure ulcer is a red localized area with the skin intact. The nurse did not documented the ulcer because she thought it would resolve soon. Next month, the nurse did not check the status of the ulcer, and the ulcer progressed to a decubitus ulcer, gangrenous and with cellulitis. The family transported the patient to the hospital, with fever, severe pain, and shortness of breath; the patient died four days later. The family sue the nurse, due to failure to document the pressure ulcer timely and to prevent the progress of the decubitus ulcer, infection, and hospitalization. Most cases of nursing malpractice and negligence are preventable. Several organizations and government agencies develop guidelines, regulations, goals, quality

Every day millions of people enter some type of health care facility seeking medical treatment. They go to these places because they trust the physicians, nurses, and all other medical personnel are there to provide them with adequate, quality care with hopes that they will be discharged in a healthier state. Inadvertently, each day millions of people entering these facilities and experiencing more complications than expected due to some type of medical error. Medical errors are becoming more and more frequent every day and its costing patients more than ever.

According to, World Health Organisation Patient Safety Report(2012), 1 in 10 patients receiving care in a developing country like India is harmed while receiving hospital care by a range of errors or adverse events. Similarly, there is much higher, up to a 20-fold risk of acquiring healthcare ­ associated infection in developing countries compared to developed countries. (Patient Safety Report; 2012) This implies that with nearly 1 in 300 chance of a patient harm, health care in developing countries is a high-risk industry amounting to high financial impact on these nations. (Patient Safety Report; 2012) An investigation conducted by Health Department, Rajkot Municipal Corporation found similar results which led to some drastic changes within its programs, following its internal publication. This essay will aim to explore the key challenges faced by the department in ensuring quality and safety of health services, how these challenges were addressed by building clinical leadership and ensuring effective, blame free communication at all levels of patient safety. Thus, by making every care provider working in the department responsible for the quality of care and patient safety, the department was not only able to greatly improve outcome for their consumers but also popularize its service and won several states as well as national accolades for

Lastly, but most importantly, we have all seen various the headlines and hospitals in the news. It can happen so quick… where a complex instrument is found to have retained debris-even after it went through the proper cleaning and sterilization steps as per directed within the manufacturers IFU. Or the instrument fell apart during a procedure and through investigation, was found that it was not properly inspected prior to the surgical procedure. We must all pull together to avoid these potential adverse events become proactive in the proper inspection, cleaning, repair and preventative maintenance; for both patient safety and for the reputation of our facilities.

The origins of the statement “time is of the essence” are unknown, however this term is widely used in business transactions with the implication that the task at hand will be completed within the time parameters specified, and if no speciation is provided than as expediently as possible (West’s Encyclopedia of American Law, edition 2, 2008). Never was this statement more true than when used in regards to responding to critical lab values or adverse findings in diagnostic studies, which, in this instance, could literally mean the difference between life and death. Effective and timely communication between the departments that identify critical lab value or adverse diagnostic finding, the nursing staff, and the attending or consulting physicians is essential in consistently achieving this goal in acute care hospitals as outlined by The Joint Commission.

With the numerous patients a medical staff encounter, unintended harm can occur while the patient is under their care and may not be properly addressed. Reporting on the figures for preventable harm in American hospitals began in 1999 with roughly 98,000 people estimated dying from these errors and another million injured by the Institute of Medicine (Landrigan et al., 2010). These errors occur in various forms from a forgotten surgical tool in the patient to incorrect dosages of