Medical Errors also Diminish Patient Safety
As a student of healthcare quality management, it is vital that you are able to identify problems that arise in healthcare organizations and propose strategies for their improvement. A critical part of this process requires you to be familiar with quality and accreditation standards and navigate the communication channels of the organization. For your summative assignment, you will identify a departmental problem within a healthcare organization and develop a collaborative performance improvement initiative to address it. Ideally, the proposed evidence-based solution will serve to improve the departmental problem, thus contributing to the overall success of the healthcare organization. The project is divided into three milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Two, Four, and Seven. The final product will be submitted in Module Eight. In this assignment, you will demonstrate your mastery of the following course outcomes: • Evaluate appropriate methods of healthcare data collection and interpretation for informing organizational decision making • Assess healthcare performance improvement initiatives for addressing gaps in organizational performance • Evaluate requirements of current quality and safety initiatives for how they promote the culture of safety in healthcare organizations • Formulate communication and teamwork strategies in quality management that engage diverse stakeholders within healthcare organizations • Evaluate information management systems and patient care technologies that promote healthcare quality Prompt Begin by identifying an organizational problem within your own workplace healthcare setting or a hypothetical healthcare organization. Propose an initiative that addresses this chosen problem, utilizing evidence-based literature and quality standards. If you choose a problem in your workplace, be sure to utilize data from that healthcare organization; if you have created a hypothetical healthcare organization, you may use a public domain database with instructor permission. As this is a scholarly initiative, this assignment must adhere to all APA requirements and formatting and include peer-reviewed and evidence-based sources to support any and all claims. Specifically, the following critical elements must be addressed: I. What Is the Organizational Problem? a) Provide the organizational problem that you have chosen. How does this problem fail to meet quality or other regulatory requirements? b) Articulate organizational challenges posed by the problem (e.g., interdepartmental conflicts, communication failure, budgeting issues). II. Evidence-Based Support a) Provide data that supports the existence of the problem. You may utilize public sources to find data related to your selected problem. 2 b) How has this problem been addressed in the past? What information management systems or patient care technologies have been utilized when addressing this problem? Be sure to use peer-reviewed literature to support your answer. Discuss relevant accreditation standards, safety standards, compliance standards, and quality initiatives. How do these standards promote a culture of safety within the department? Be sure to cite the appropriate standards within your answer. III. Performance Improvement Initiative a) Propose an initiative that will address this problem within the department of your chosen healthcare organization. What specific relevant quality standard will this quality initiative address? b) Describe the type of data that will reveal a quality outcome. IV. Implementation of the Plan in the Organization a) How will this implementation plan be communicated among departments? b) How will the data be displayed and shared with the organization? c) If the plan for this initiative was implemented, what do you believe would be the hypothetical effect(s) on patient care outcomes? How will health information systems support those improvements in patient care? d) What do you think the hypothetical effect of the quality or performance plan would be on the culture of safety within the organization? V. Success of the Performance Improvement Plan a) If this initiative is successful, how would the organization monitor the financial implications ? b) How would the current information management systems contribute to the success of your plan? c) What current organizational processes will help the plan be successful? d) How will the plan be communicated among departments? How will this communication help team members commit to the performance improvement plan? Milestones Milestone One: Identify Organizational Problem In Module Two, first, you will identify a problem in a healthcare organization. You may use a problem from your organization or a problem from a fictional organization. This milestone is graded with the Milestone One Rubric. Milestone Two: Initiative Proposal In Module Four, you will build upon the work you completed on milestone one. In this milestone, you will propose an improvement plan that focuses on the problem you selected in Milestone One. If you chose a problem in your workplace, be sure to use data from that healthcare organization; if you created a hypothetical healthcare organization, you might use a public domain database with instructor permission. Next, you will develop an implementation plan for the problem that you are focusing on. Then, you will discuss the predicted success of the performance improvement plan after implementation. This milestone is graded with the Milestone Two Rubric. Milestone Three: Implementation of Performance Initiative 3 In Module Seven, you will implement your performance improvement plan. Also, you will discuss what success of the performance improvement plan will look like. If you choose a problem in your workplace, be sure to use data from that healthcare organization. If you created a hypothetical healthcare organization, you might use a public domain database with instructor permission. This milestone is graded with the Milestone Three Rubric. Final Submission: Organizational Performance Initiative In Module Eight, you will submit your final project. The final project should be a complete, polished paper containing all of the items listed on the grading rubric. Your paper should show that you have applied all of the instructor feedback. This submission is graded with the Final Project Rubric.
Medical errors have been regarded as one of the most serious problems causing deaths in the United States. As a major health issue, policy and practice developments have taken place to help address the adverse effects caused by medical errors. Many healthcare organizations today have been faced with this challenge and have undertaken to implement strategies and programs designed to reduce medical errors. The focus of this paper is to describe the problem of medical errors and to propose performance improvement initiatives to reduce the effects of the problem. The selected healthcare organization will be given the name XYZ for this paper.
Organizational Problem: Medical Errors
The term ‘medical errors’ has appeared extensively in the current literature on healthcare quality. By definition, medical errors refer to preventable events that cause or lead to negative medication outcomes, including harm to and diminished safety of the patients (Billstein-Leber et al., 2018). Medical errors occur during professional practice, which means that they occur when patients are under the care of a practitioner. Similarly, the errors may result from other practices, including prescriptions, product labeling, packaging, and order communication. One of the major healthcare outcomes sought by patients is quality of life through minimal risk and positive care outcomes. However, medical errors tend to negate this expectation and place patients at risk of greater health problems or even mortality. Similarly, medical errors also diminish patient safety, another area that is usually under strict regulation. Healthcare organizations also have developed quality assurance principles and regulations to help ensure high-quality care. Medical errors could be an indication that the practitioners failed to follow the quality requirements or that the organization's quality assurance framework is inadequate.
Medical errors pose multiple organizational challenges for healthcare providers. One of the problems is that medical errors can cause healthcare organizations massive financial costs. In essence, patients could sue hospitals for damages caused by the errors (Hooiveld, 2021). In addition to the lawsuit costs, paying damages to patients can prove very costly. These costs could also pose another challenge in budgeting due to the financial constraints caused by medical errors. Hospitals prone to errors and expensive lawsuits could be forced to budget for such uncertainties. Depending on the sources of the errors, interdepartmental conflicts can emerge as each unit blames the errors on others or practitioners across departments fail to be accountable and take responsibility. Communication breakdown may also occur due to the conflicts. Most importantly, hospitals can damage their reputation when they become renowned for medical errors, especially when such errors cause such extreme outcomes as patient death.
Evidence-Based Support
Current evidence to illustrate the existence of the problem can be derived from multiple sources, especially the news media and empirical research. According to Sipherd (2018), medical errors are the third-leading cause of death in the United States. This fact was established in a recent John Hopkins study that revealed that annual deaths in the US average over 250000. The study also revealed that the death figures could reach upwards of 440000 annually. With these statistics, it means that only heart disease and cancer cause more deaths in the country than medical errors. Despite the high number of deaths associated with the problem, further studies reveal that only 10% of medical errors are reported (Anderson & Abrahamson, 2017). Therefore, this is evidence that the existence of the problem remains concealed and masked by the failure or reluctance to report it.
Some stories in the news media describe the incidences as they happened. For example, the story told in the article by Sipherd (2018) involved a young girl who received 20 times the recommended dose of sodium chloride on her final day of cancer treatment. A few hours after this error the young girl was declared brain dead and died after three days. Even though not many stories will make it to the media, the current mortality statistics due to medical errors not only show the existence of the problem but also how serious a threat it is to public health.
Current practice and literature highlights several efforts to resolve the challenge of medical errors. For example, the American Society of Health-System Pharmacists (ASHP) recently developed a medication management system designed to reduce medical errors. The system comprised such elements as an event reporting system, an interdisciplinary medication safety team, designs for assessing and reducing risks, and a philosophy of continuous improvement (Billstein-Leber et al., 2018). Information management systems have been central to these efforts, for example, the use of bar code technology for preparing, dispensing, and administering medications. Other information technologies include data mining, BCMA compliance, and computer alerts. According to Ambwani et al (2019), computerized physician order entries, electronic medical reconciliation, and automated dispensing cabinets have been extensively used as tools for reducing medical errors. Overall, it can be argued that information systems have been used to replace human inputs that have been the cause of most medical errors.
Accreditation, safety, and compliance standards and quality initiatives have also been used to promote a culture of safety within the organization. Accreditation organizations include the AAAHC, the National Committee for Quality Assurance, and The Joint Commission. For example, AAAHC focuses on ambulatory healthcare and offers certification to providers (AAAHC, n.d.). The Patient Safety and Quality Improvement Act of 2005 (PSQIA) regulates patient safety through a compliance framework involving a reporting system (Health and Human Services, n.d.). These standards have targeted the major problem areas, which helps make improvements through the development of a safety culture.
Performance Improvement Initiatives
XYZ can implement several performance improvement initiatives to help address the problem. As mentioned earlier, the fact that only 10% of medical errors are reported means that much of the problem goes undetected, which makes it difficult to address. In this case, a reporting system is considered the ideal starting point for this organization. As a performance improvement initiative, the reporting system seeks to record and report all actions of the physicians and other practitioners across all departments. By logging all actions, the sources of errors can be identified and reported by the individuals who first notice them. additionally, the reporting system is part of a broader information system that seeks to digitize multiple patient care practices. As a result, computer alerts provide an early warning system, which means that the errors could be automatically reported once identified. The major quality standard that will be followed is the PSQIA. The rationale is that this quality standard also focuses on reporting as a mechanism to help reduce medical error...