Write 8-10 pages in which you identify a major patient-safety issue within your own organization and use evidence-based best practices and technology to develop a plan to improve the safety issue.
Preparation
As you prepare for this assessment, complete the following:
- Before you begin, examine your organization’s history of safety in a specific area and how your organization addresses patient safety issues. If possible, consult with a key stakeholder in the organization (such as an administrator) to better understand specific patient-safety concerns and how the organization is working to resolve the concerns. This person should also be able to discuss some of the organizational barriers impacting the patient safety issue.
- Next, look at the basic concepts, principles, and practices that contribute to organizational quality improvement and patient safety. Review the literature for best practices and how technology might be used to improve the issue.
- Finally, be sure to consider the legal and ethical implications associated with the safety issue, as well as possible organizational barriers to change.
Directions
As you construct this assessment, address each point as completely as possible:
- Describe a patient-safety issue within your organization, comparing the way your organization addresses the issue with the concepts, principles, and practices that contribute to quality improvement and patient safety.
- Analyze the legal and ethical consequences of not addressing the issue.
- Recommend evidence-based interventions, including technology, to address the patient-safety issue.
- Describe strategies to overcome specific organizational barriers to change, based on your knowledge of the organization.
Additional Requirements
- Format: Include a title page and reference page. Use APA style and formatting.
- Length: Ensure your completed assessment is 8–10 pages in length, not including the title page and reference page.
- References: Cite at least five current scholarly or professional resources.
- Font: Use double-spaced, 12-point, Times New Roman font.
Expert Solution Preview
Introduction:
In this assignment, we will identify a major patient safety issue within a medical organization and develop a plan to improve the safety issue using evidence-based best practices and technology. We will examine the organization’s history of safety in a specific area and how it currently addresses patient safety issues. We will also consider the legal and ethical implications associated with the safety issue and explore possible organizational barriers to change.
1. Describe a patient-safety issue within your organization, comparing the way your organization addresses the issue with the concepts, principles, and practices that contribute to quality improvement and patient safety.
One of the major patient safety issues within our organization is medication errors. Despite having established protocols and procedures in place, medication errors still occur frequently. This issue is significant as it can lead to adverse drug events, patient harm, and even mortality.
Our organization requires healthcare professionals to adhere to medication administration best practices, such as the five rights of medication administration and the use of barcode medication administration (BCMA) technology. However, there are still gaps in the system that contribute to medication errors, including distractions, high workload, lack of standardized processes, and inadequate communication.
To address this patient safety issue, we need to further integrate and utilize evidence-based practices and technologies. This includes implementing computerized physician order entry (CPOE) systems, which can minimize errors at the prescribing stage. By utilizing decision support systems within the CPOE, clinicians can receive alerts and warnings related to dosage errors, drug interactions, and allergies, thereby reducing medication errors.
Additionally, the implementation of smart infusion pumps can help prevent medication errors during administration. These pumps are programmed with limit ranges and alerts, enhancing accuracy and preventing adverse events. By integrating BCMA technology with smart infusion pumps, the risk of medication errors can be further reduced by ensuring the right medication is administered to the right patient at the right time.
2. Analyze the legal and ethical consequences of not addressing the issue.
Failure to address the medication error issue can have severe legal and ethical consequences. From a legal perspective, medication errors can result in malpractice lawsuits, damaged reputation, and significant financial burdens for the organization. Patients or their families may seek legal action if harm or adverse events occur due to medication errors. In addition, regulatory authorities may impose penalties and sanctions on the organization for non-compliance with patient safety standards.
Ethically, medication errors can compromise patient trust and lead to breaches in the duty of care. Patients have the right to receive safe and effective medication management, and failure to address medication errors can violate this fundamental patient right. It is the ethical responsibility of healthcare professionals and the organization to prioritize patient safety and ensure that every effort is made to prevent harm resulting from medication errors.
3. Recommend evidence-based interventions, including technology, to address the patient-safety issue.
To address the medication error issue effectively, the following evidence-based interventions and technologies should be considered:
a) Implementation of CPOE systems: CPOE systems have demonstrated effectiveness in reducing medication errors by providing decision support, minimizing handwriting errors, and facilitating electronic communication between healthcare professionals. This intervention can significantly improve the safety of the medication prescribing process.
b) Utilization of smart infusion pumps: Smart infusion pumps with built-in safety features can help prevent errors in medication administration. These pumps can calculate and deliver accurate dosages, provide alerts for potential errors, and enhance the overall safety of intravenous medication administration.
c) Integration of BCMA technology: Barcode medication administration technology helps ensure accurate medication administration by verifying patient identity and medication details at the point of care. By scanning barcodes on patients’ wristbands and medication packages, healthcare professionals can confirm that the right medication is being administered to the right patient, thereby reducing the risk of medication errors.
4. Describe strategies to overcome specific organizational barriers to change, based on your knowledge of the organization.
To overcome specific organizational barriers to change and successfully implement the recommended interventions, the following strategies can be employed:
a) Leadership support and engagement: Strong leadership support is crucial for driving organizational change. Leaders should champion the importance of patient safety and foster a culture of continuous improvement. Creating a dedicated patient safety committee that includes representatives from various departments can ensure collaboration and accountability in addressing medication errors.
b) Staff education and training: It is essential to provide comprehensive education and training to healthcare professionals on evidence-based best practices, the use of new technologies, and the importance of patient safety. This can be achieved through regular workshops, seminars, and online learning modules.
c) Encouraging open communication and reporting: Establishing a non-punitive reporting system for medication errors can encourage healthcare professionals to report incidents without fear of retribution. This information can be valuable in identifying systemic issues and implementing effective strategies to prevent future errors.
d) Continuous monitoring and feedback: Implementing a robust monitoring and feedback system is crucial to sustain improvements in patient safety. Regular audits, incident analysis, and feedback sessions can help identify areas for improvement and track progress over time.
e) Collaboration with technology vendors: Collaborating with technology vendors and involving them in the implementation process can ensure the successful integration of new technologies. Vendors can provide guidance, training, and ongoing support to optimize the functionality and effectiveness of the implemented systems.
In conclusion, addressing patient safety issues within an organization requires a comprehensive approach that encompasses evidence-based interventions and technological advancements. By comparing the current practices with best practices in quality improvement and patient safety, organizations can identify areas for improvement. The legal and ethical consequences of not addressing patient safety issues highlight the urgency and importance of implementing effective strategies. Overcoming organizational barriers to change is crucial for successful implementation, and strategies such as leadership support, staff education, open communication, continuous monitoring, and collaboration with technology vendors can facilitate the transformation towards a safer healthcare environment.
