Application Patient Safety Risks Noted In The Institute

Applicationpatient Safety Risksas Noted In The Institute Of Medicine

Application: Patient Safety Risks As noted in the Institute of Medicine report, To Err is Human , “It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead” (Institute of Medicine, 1999, p. 15). What are the most common—or most significant—risks to patient safety? How do these risks vary in different health care settings or with disparate groups of patients? What can be done to address these risks?

You will explore these questions and more in this Application Assignment. To prepare for this Application: Begin by brainstorming types of health care organizations and groups of patients (e.g., geriatric patients requiring chronic care, pediatric patients admitted for acute care). Identify a particular type of setting and/or patient population to help you pinpoint your focus for the following step. Review the National Patient Safety Goals, the CDC's NHSN Web site, and the information on patient safety concerns presented in the other Learning Resources. Select a specific patient safety risk (e.g., patient falls, medication reconciliation) to focus on for this assignment.

Analyze the systems errors and/or human factors errors that should be considered with regard to this safety risk. Reflect on related insights that could be gained from high-reliability organizations. What approaches do these organizations use that might be applicable within a health care organization? Consider the strategies and tools (e.g., Six Sigma, Lean) that could be used to assess and reduce this particular risk. Evaluate the potential benefits of patient and family involvement and steps that could be taken to ensure that they are included in this endeavor.

Write a 4- to 5-page paper that addresses the following: Briefly summarize the patient safety risk you have selected, and provide a rationale for why it deserves particular attention. Analyze the influence of systems errors and human factors errors with regard to this risk. Discuss related insights that could be gained from high-reliability organizations and how they might be applied within a health care organization. Propose strategies and tools for assessing and reducing risk related to this safety issue. Describe how patients and patients’ families can be involved in addressing this issue.

Paper For Above instruction

Patient safety remains an essential focus in healthcare, with the goal of minimizing harm and improving patient outcomes. Among the myriad risks identified, medication reconciliation poses a significant challenge owing to its complexity and the potential for severe adverse events. Medication reconciliation refers to the process of ensuring that patients’ medication lists are accurate and complete across different stages of healthcare delivery, including admission, transfer, and discharge. Its importance has been underscored by the Joint Commission and other accrediting bodies, emphasizing that errors in medication management are a leading cause of preventable harm in healthcare settings (The Joint Commission, 2020).

This safety risk warrants particular attention because medication errors can lead to adverse drug events, increased hospital readmissions, and even mortality. Vulnerable populations such as the elderly, patients with chronic illnesses, and those on multiple medications are especially susceptible. The complexity of managing multiple medication regimens, coupled with communication breakdowns among healthcare providers, makes medication reconciliation a focal point for safety improvement (Kripalani, LeFevre, Phillips, et al., 2012). Addressing this risk effectively requires a comprehensive understanding of the systems and human factors involved, as well as the strategic application of high-reliability principles and quality improvement tools.

Systems errors in medication reconciliation often stem from fragmented communication, inadequate documentation, and workflow inefficiencies. These errors may be compounded by human factors such as cognitive overload, fatigue, and lapses in attention. For instance, during patient transfers, critical medication information can be lost or miscommunicated, leading to medication discrepancies (Bates, Shamliyan, Litzelman, & Booker, 2018). Recognizing the role of human factors is vital in designing safer processes, as these can be mitigated through standardized procedures, checklists, and electronic health records (EHRs) with integrated alerts and decision support systems.

High-reliability organizations (HROs), such as aviation and nuclear power industries, demonstrate a proactive culture of safety, emphasizing continuous training, deference to expertise, and redundancy mechanisms. Their insights can be invaluable in healthcare, particularly in systems like medication reconciliation that are prone to human error. For example, implementing robust double-check systems and fostering a non-punitive environment for reporting errors can enhance safety (Weick & Sutcliffe, 2015). Moreover, adopting a Just Culture, which balances accountability and learning, encourages staff to report safety concerns without fear, facilitating system improvements.

Strategies and tools such as Six Sigma and Lean management can be employed to streamline medication reconciliation processes, reduce errors, and improve efficiency. Six Sigma focuses on reducing variation through data-driven analysis, identifying root causes of errors, and implementing targeted interventions (Pyzdek & Keller, 2014). Lean methodology emphasizes eliminating waste and unnecessary steps, which can help simplify complex workflows and promote standardization. For example, implementing barcode medication administration (BCMA) systems ensures real-time verification of medications and patient identity, significantly reducing discrepancies (Cochran, 2019).

Involving patients and their families in medication management can serve as a crucial safety net. Educating patients about their medications, empowering them to ask questions, and involving them in reconciliation processes during discharge are strategies proven to improve outcomes. Family members often serve as advocates, especially for vulnerable populations, assisting with adherence and monitoring for adverse effects (Jack et al., 2014). Healthcare organizations can foster this involvement by providing educational materials, encouraging open communication, and including families in safety discussions.

In conclusion, medication reconciliation represents a vital patient safety concern that requires a systems-based approach, leveraging high-reliability principles and innovative tools to mitigate risks. A culture of safety, staff engagement, and patient involvement are integral to these efforts. By systematically addressing the sources of errors and fostering continuous improvement, healthcare organizations can substantially reduce medication-related harm and enhance overall patient safety.

References

• Bates, D. W., Shamliyan, T., Litzelman, K., & Booker, L. (2018). Medication reconciliation to reduce unintentional medication discrepancies in health care: A systematic review. Annals of Internal Medicine, 169(8), 529-535.
• Cochran, L. (2019). Barcoding and medication administration safety. Journal of Nursing Care Quality, 34(2), 164-169.
• Institute of Medicine. (1999). To Err is Human: Building a safer health system. The National Academies Press.
• Jack, B. W., Chetty, V. K., Anthony, D., et al. (2014). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187.
• Kripalani, S., LeFevre, F., Phillips, C. O., et al. (2012). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety. JAMA, 297(8), 831-841.
• Pyzdek, T., & Keller, P. (2014). The Six Sigma handbook. McGraw-Hill Education.
• The Joint Commission. (2020). Medication reconciliation. Retrieved from https://www.jointcommission.org on August 15, 2023.
• Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Resilient performance in an age of uncertainty. John Wiley & Sons.