BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue:

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Introduction

Concerns about patient safety are very important to the healthcare sector. Problems with patient safety can be avoided in a number of ways. I will examine and evaluate a patient safety issue scenario as part of my assessment. I will then assess the dangers connected to the chosen patient safety concern. Finally, I’ll go over the responsibilities of the patient safety office and offer suggestions on how to resolve the patient safety problem.

This evaluation will identify and analyze the patient safety concern as well as concentrate on putting evidence-based procedures and policies in place that can reduce such risks. Through an analysis of the current protocols and their efficacy, we are able to identify areas that require enhancement and suggest focused treatments.

 In addition, the investigation will encompass a full grasp of how comparable concerns have been handled in other healthcare settings by reviewing pertinent case studies and literature. Creating implementable plans that increase overall patient safety and support a continuous improvement culture is the aim. Finally, in order to provide recommendations that are both practical and long-lasting, it will be crucial to interact with frontline healthcare workers and take their observations into consideration.

Related Assessments:

BHA FPX 4010 Assessment 1

BHA FPX 4010 Assessment 2

BHA FPX 4010 Assessment 3

Scenario of a Patient Safety Issue

Patient medication errors constituted a patient safety risk for Vila Health. In this case study, there were two patients with similar names and dates of birth who were in close proximity to one another: B. Moore (born on August 11, 2005) and B.R. Moore (born on November 8, 2005). Due to patient identification errors resulting from name similarity, a medication error occurred.

Before the prescription mishap, Kyra Dailey, the patient safety officer (PSO), recognized the name similarities. Virginia Anderson, the charge nurse of the unit where both Moore patients were being treated, was contacted by the PSO. The charge nurse told her that extra safety measures were being taken, like allocating separate nurses to each Moore patient, in an attempt to prevent any issues (Moore et al., 2022).

However, the charge nurse also mentioned that they had a staff turnover problem due to understaffing. Not only are name and birthday coincidences a high-risk factor for patient safety errors in this case, but staffing shortages also pose a risk. These elements raised the possibility of patient safety errors, and it was evident from the conversation between Arthur Chester, the risk manager, and the PSO how the prescription error was made. Insulin was prescribed to Patient B. Moore.

Ida Feeney of pediatric services and Brenda Turner, a nurse, discussed her health and found that she did not have an order for insulin. Low blood sugar can occur when insulin is administered when it is not necessary (PMC, 2020). Low blood sugar can cause a variety of symptoms, such as dizziness, nausea, vomiting, heart palpitations, and even death. This is an excellent illustration of why providing high-quality care requires patient safety. A healthcare organization’s ability to reduce costs and expenses, retain regulatory agency accreditation, and build patient and family confidence all depend on its ability to improve patient safety through the prevention of near misses, adverse events, and sentinel events.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

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Consequences of Ignoring the Threat

When a patient safety threat is ignored, there can be a lot of consequences. Even if the error may have been unintentional, failing to resolve it appropriately can lead to ongoing prescription errors and patient identity issues, higher expenses for the healthcare system, negative consequences for patient health, and more stringent regulatory scrutiny (Chen & Miraldo, 2022). Policies are put into place by regulatory organizations like The Joint Commission (TJC) to enhance and promote patient safety. In all areas of healthcare, patient quality comes first.

An adverse event or sentinel event is/may be harmful for the patient, family, and staff in the event of a prescription error, as demonstrated in the Vila Health scenario for B. Moore. Reporting incidents to management is necessary for patient safety officer and giving the TJC reports. Every three years, the TJC surveys healthcare organizations. The survey comprises management and personnel as well as safety inspections. As a result, the TJC is able to inform and raise awareness about patient safety. Errors in patient safety may have dire consequences, including penalties, staff firing, and accreditation loss (Stowell et al., 2020). 

The Function of Patient Safety Officers in the Successful Execution of Patient Safety Plans

Ensuring patients receive high-quality healthcare is the responsibility of the patient safety officer (PSO). The PSO carries out this duty by locating issues within the healthcare system and creating plans to stop and fix them. Health Affairs claims that enhancing patient satisfaction, enhancing population health, and lowering per-capita health care costs are safety imperatives (Crowley et al., 2020). The PSO recognized a patient safety risk in the medication error scenario involving B. Moore at Vila Health when they observed two patients who shared the same name and birthday close to one another. As per protocol, the PSO was also informed when the drug error happened.

The PSO makes sure that patient safety regulations are followed and speaks with personnel and the healthcare organization on behalf of the patient or family when they have questions or concerns. For instance, in accordance with legal obligations, the PSO creates policies and procedures for the healthcare company. As part of legal compliance, this may entail reporting events to PSO within 24 hours, who will then make sure the patient or family is informed and reports the incident to the Joint Commission. Repercussions for multiple patient safety errors may include loss of accreditation or heightened regulatory scrutiny (Erickson et al., 2020).

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

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Suggestions to Minimize the Risk to Patient Safety

To address and maybe prevent a risk to patient safety, various strategies and tactics can be used. In the Vila Health case of B. Moore, one of the patients ought to have been moved as soon as the PSO realized that two patients with the same name and birthdate were close together and that the unit was understaffed. Furthermore, the patient’s identity ought to have been appropriately verified. The patient’s name, birthdate, or medical record number are the three patient identifiers that may have been confirmed in order to accomplish this (Sragow et al., 2020) . Last but not least, a name alert might have been put on the patient’s identifying band, door post, or chart.

This would have served as a warning to any staff members entering their room to proceed with caution due to the similarity in names. In an effort to prevent patient safety errors in the future, the PSO can offer an in-service to teach the doctors who made the mistake and other staff members on the unit what protocols to take when you have patients with similar names.

Conclusion

According to Kohn, Corrigan, and Donaldson (1999), medical errors in hospitals result in the deaths of about 98,000 people each year. When you take into account patients who have been impacted by patient safety mistakes in other healthcare settings, like assisted living homes, rehabilitation centers, and outpatient clinics, the total grows even more. There is a great deal of duty on the patient safety office. Even though they create procedures to stop and fix patient safety mistakes, the organization’s whole staff of medical professionals must be accountable enough to carry out and enforce these procedures in the course of their regular work.

Everyone should be inspired to give their all to guarantee the patient has the finest experience by keeping in mind that the quality of care comes first. A safe experience ought to be the greatest kind. This would ensure that the organization’s operations would last for a long time, enabling it to keep its accreditation, provide jobs for its employees, and establish a secure atmosphere in which patients may receive the treatment they require to flourish.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

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Reference

Chen, J., & Miraldo, M. (2022). The impact of hospital price and quality transparency tools on healthcare spending: a systematic review. Health Economics Review, 12(1). https://doi.org/10.1186/s13561-022-00409-4

Crowley, R., Daniel, H., Cooney, T. G., & Engel, L. S. (2020). Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care. Annals of Internal Medicine, 172(2), 7–32. https://doi.org/10.7326/m19-2415

Erickson, S. M., Outland, B., Joy, S., Rockwern, B., Serchen, J., Mire, R. D., & Goldman, J. M. (2020). Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms. Annals of Internal Medicine, 172(2), S33. https://doi.org/10.7326/m19-2407

Moore, D. J., Dawkins, D., Hampton, M. D., & McNiesh, S. (2022). Experiences of critical care nurses during the early months of the COVID-19 pandemic. Nursing Ethics, 096973302110432. https://doi.org/10.1177/09697330211043273

PMC, E. (2020, April 21). Blood Glucose Monitoring. Europepmc.org. https://europepmc.org/article/NBK/nbk555976

Sragow, H. M., Bidell, E., Mager, D., & Grannis, S. (2020). Universal Patient Identifier and Interoperability for Detection of Serious Drug Interactions: Retrospective Study. JMIR Medical Informatics, 8(11), e23353. https://doi.org/10.2196/23353

Stowell, N., Pacini, C., Wadlinger, N., Crain, J., & Schmidt, M. (2020). Investigating Healthcare Fraud: Its Scope, Applicable Laws, and Regulations. William & Mary Business Law Review, 11(2), 479. https://scholarship.law.wm.edu/wmblr/vol11/iss2/5/

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