safety quality issue in a health care setting
- For this assessment, you will develop a 3-5 page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement. You may also choose to use the scenario in the activity as the basis for your assessment.
DEMONSTRATION OF PROFICIENCY
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
- Competency 1: Analyze the elements of a successful quality improvement initiative.
- Explain evidence-based and best-practice solutions to improve patient safety related to a specific patient safety risk and reduce costs.
- Competency 2: Analyze factors that lead to patient safety risks.
- Explain factors leading to a specific patient safety risk.
- Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
- Explain how nurses can help coordinate care to increase patient safety and reduce costs.
- Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements.
- Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
- Communicate using writing that is clear, logical, and professional with correct grammar and spelling using current APA style.
Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
Consider the hospital-acquired conditions that are not reimbursed under Medicare/Medicaid, some of which are specific safety issues such as infections, falls, medication errors, and other concerns that could have been prevented or alleviated with the use of evidence-based guidelines.Choose a specific condition of interest and incorporate evidence-based strategies to support communication and ensure safe and effective care. For this assessment, consider using one of the following approaches:
- Expand on the scenario presented in Vila Health: Identifying Patient Safety Concerns and analyze a quality improvement (QI) initiative.
- Analyze a current issue in clinical practice and identify a quality improvement (QI) initiative in the health care setting.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.
- Explain factors leading to a specific patient-safety risk.
- Explain evidence-based and best-practice solutions to improve patient safety related to a specific patient-safety risk and reduce costs.
- Explain how nurses can help coordinate care to increase patient safety and reduce costs.
- Identify stakeholders with whom nurses would coordinate to drive safety enhancements.
- Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
- Length of submission: 3–5 pages, plus title and reference pages.
- Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
- APA formatting: References and citations are formatted according to current APA style.
Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click the linked resources for helpful writing information.Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course.
- Competency 1: Analyze the elements of a successful quality improvement initiative.
Use the scoring guide to understand how your assessment will be evaluated.
Enhancing Quality and Safety Scoring Guide CRITERIA NONPERFORMANC E BASIC PROFICIENT DISTINGUISHE D Explain factors leading to a specific patient safety risk. Does not identify factors leading to a specific patient safety risk. Identifies factors leading to a specific patient safety risk. Explains factors leading to a specific patient safety risk. Explains factors leading to a specific patient safety risk. Makes reference to specific data, evidence, or standards illustrate the safety risk. Explain evidencebased and best-practice solutions to improve patient safety related to a specific patient safety risk and reduce costs. Does not identify evidence-based and bestpractice solutions to improve patient safety related to a specific patient safety risk and reduce costs. Identifies evidencebased and best-practice solutions to improve patient safety related to a specific patient safety risk and reduce costs. Explains evidencebased and best-practice solutions to improve patient safety related to a specific patient safety risk and reduce costs. Explains evidence-based and best practice solutions to improve patient safety related to a specific patient safety risk and reduce costs. Makes explicit reference to scholarly or professional resources to support explanation. Explain how nurses can help coordinate care to increase patient safety Does not identify how nurses can help coordinate care to increase patient safety and reduce costs. Identifies how nurses can help coordinate care to increase patient safety and reduce costs. Explains how nurses can help coordinate care to increase patient safety and reduce costs. Explains how nurses can help coordinate care to increase patient safety and reduce costs, providing specific examplessafety quality issue in a health care setting
CRITERIA NONPERFORMANC E BASIC PROFICIENT related to a patient safety risk. and reduce costs. Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements . Does not identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements. Identifies stakeholders, but their relevance to collaboration with nurses or their ability to drive quality and safety enhancements is unclear. Identifies stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements . Identifies stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements, noting the relevance and potential importance of the stakeholders. Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Does not communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Communicate s using unclear or illogical writing that contains many errors in grammar or APA style. Communicate s using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Communicates using writing that is clear, logical, and professional, with correct grammar and spelling, using error-free, current APA style. Resources: • • DISTINGUISHE D Collaboration and Leadership Falls, E., & Hensel, D. (2012). Characteristics that perinatal nurse managers desire in new o • o • o • • o • nurse hires. The Journal of Continuing Education in Nursing, 43(4), 182–187. This article may be helpful with identifying ways to coordinate and lead quality and safety measures related to the assessment. McInnes, S., Peters, K., Bonney, A., & Halcomb, E. (2015). An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. Journal of Advanced Nursing, 71(9), 1973–1985. This literature review may be a useful source for evidence and best practices to integrate into your assessment. Strech, S., & Wyatt, D. A. (2013). Partnering to lead change: Nurses’ role in the redesign of health care. AORN Journal: The Official Voice of Perioperative Nursing, 98(3), 260–266. This article examines competencies that may help nurses collaborate more effectively to improve patient outcomes. Quality Improvement Initiatives Allison, J. (2016). Ideas and approaches for quality-assessment and performanceimprovement projects in ambulatory surgery centers. AORN Journal, 103(5), 483–488. This article focuses on approaches and indicators customary to the services and operations of an ambulatory surgery center, going beyond reviewing data from routine outcome measures and explaining the effect these ideas can have on improving quality of care. Coles, E., Wells, M., Maxwell, M., Harris, F. M., Anderson, J., Gray, N. M., . . . MacGillivray, S. (2017). The influence of o • o • o • • o contextual factors on healthcare quality improvement initiatives: What works, for whom and in what setting? Protocol for a realist review. Systematic Reviews, 6, 168–178. Retrieved from safety quality issue in a health care settinghttps://systematicreviewsjournal.biomedcentral. com/articles/10.1186/s13643-017-0566-8 This article examines ways in which the context of a quality improvement initiative plays a role in its success or failure and should help you consider the context of your proposed quality improvement initiative. Institute for Healthcare Improvement. (n.d.). Reliability series part 1: What is reliability? [Video]. Retrieved from http://www.ihi.org/education/IHIOpenSchool/r esources/Pages/Activities/FrankReliability1.asp x This video discusses the relationship between reliability and quality in health care. Lawton, R., Carruthers, S., Gardner, P., Wright, J., & McEachan, R. R. C. (2012). Identifying the latent failures underpinning medication administration errors: An exploratory study. Health Services Research, 47(4), 1437– 1459. This examination of underlying systemic causes of medication errors may be useful as you consider QI best practices and ways to coordinate care to increase safety and quality. Quality and Safety Education Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Online Journal of Issues in Nursing, 18(3), 71–80. The need for implementing systemic quality improvement practices to improve patient safety and quality is discussed in this article. • o • o • o • • o Lyle-Edrosolo, G., & Waxman, K. (2016). Aligning healthcare safety and quality competencies: Quality and safety education for nurses (QSEN), the Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® standards crosswalk. Nurse Leader, 14(1), 70–75. This article attempts to align the language used in three quality and safety standards and reduce confusion for health care professionals. Masters, K. (2016). Integrating quality and safety education into clinical nursing education through a dedicated education unit. Nurse Education in Practice, 17, 153–160. doi:10.1016/j.nepr.2015.12.002 Masters discusses how nursing students’ participation in a dedicated safety and quality educational unit resulted in higher project evaluations than those of students who participated in traditional clinical rotations. Rosenblum, R. K., & Sprague-McRae, J. (2014). Using principles of quality and safety education for nurses in school nurse continuing education. The Journal of School Nursing, 30(2), 97–102. This article, which examines evidence-based and best-practice strategies for improving the care offered by school nurses, may help you identify useful strategies for your assessment. Quality and Safety Case Studies Vila Health: Identifying Patient Safety Concerns. This media simulation, which provides context for your upcoming assessment, explores rising concerns regarding the quality and safety of care at Vila Health. If you choose not to use the Vila Health simulation or a problem from your practice experience as the basis of your assessments, consider reviewing the following case studies: • • • • o Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ). Retrieved from http://www.ihi.org/education/IHIOpenSchool/r esources/Pages/Activities/AHRQCaseStudyOn safety quality issue in a health care settingeDoseFiftyPills.aspx Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. Retrieved from http://www.ihi.org/education/IHIOpenSchool/r esources/Pages/Activities/WhatHappenedtoJosi eKing.aspx Capella Writing Center Introduction to the Writing Center. Access the various resources in the Capella Writing Center to help you better understand and improve your writing. APA Style and Format • Capella University follows the style and formatting guidelines in the Publication Manual of the American Psychological Association, known informally as the APA manual. Refer to the Writing Center’s APA Module for tips on proper use of APA style and format. Capella University Library • o BSN Program Library Research Guide. The library research guide will be useful in guiding you through the Capella University Library, offering tips for searching the literature and other references for your assessments. Vila Health ® Activity Identifying Patient Safety Concerns • • • • Introduction Email Interviews Conclusion Introduction Patient safety is one of the core concerns of any health care facility. To properly ensure patient safety, a manager has to take an active approach to understanding safety risks. Aside from the impacts to individual patients, systemic unsafe conditions can lead to broader problems; patient safety data is public information, and poor performance can be a public relations crisis. There is also risk of financial crisis if the institution could lose significant amounts of reimbursement money from Medicare and Medicaid if safety problems persist. In this scenario, you will assume the role of the manager of the care unit at Clarion Court Skilled Nursing Facility in Shakopee, MN, a part of the Vila Health network. Clarion Court has experienced a rash of patient safety issues recently, and Stephen Silva, the administrator of the facility has asked you to identify an area of concern and consider how incorporating evidencebased strategies can enhance quality improvement and patient safety. Email You have an email from Stephen Silva. Email From: Stephen Silva, Administrator, Clarion Court Skilled Nursing Facility Subject: RE: Safety Scores I wanted to thank you again for agreeing to do a deep dive into this rash of safety problems we’ve been having. My eyes just about popped out of my head when we got the results of our last safety audit. Between you and me, I had nightmares that night about us making the local news. I’ve always prided myself on Clarion Court being a facility that was safe and nurturing for our patients, but the numbers don’t lie. I’m not sure what’s going on, to be honest, but I know that we need to get to the bottom of this. We owe it to the patients and their families, for one thing. And we’re also in real danger of losing a lot of our funding if CMS sees these numbers and decides to sanction our Medicare and Medicaid reimbursement. And that’s not just a bottom-line concern; if helping patients is our business, we can’t do that if we can’t stay in business. So to that end, I’d appreciate it if you could spend some time and talk to people on Clarion Court’s admin side, see what you can learn about the safety culture. After you talk to people, I’d like you to identify a particular area of concern and think about evidence-based ways we could make things better. Thanks! I look forward to hearing what you find out. best, Stephen Interviews Team Member Statements Click on each team member for further information on potential safety risks. Wendy DiPaolo Human Resources Thanks for talking to us, I think this is a great thing you’re doing. I feel like I’m in a different place from a lot of the floor staff when it comes to safety. It’s important in my world, too – wow, is it ever important – but for me it’s more a matter of making sure that everyone knows the policies and is following them. And, of course, I’m the person who gets to deal with OSHA.safety quality issue in a health care setting
The thing is, we have a real problem here with communication. The building looks like a big rectangle, right? That’s an optical illusion. It’s really just a bunch of silos, all next to each other, with very little information passing in between them. For instance: we have a safety team. I’m on it. It’s great! We have people from all over the facility on it, which is what you need. We get reports that there’s a problem. We go look at it, say yep, there’s always an ice buildup outside that door, that’s not safe. A recommendation gets written up, emailed over to maintenance. Nothing happens. Ice buildup stays. A few months later, someone finally thinks to check back into it, and it turns out the head of maintenance who’s on the safety team! – just forwarded it to one of his people and then deleted it and forgot about it. And the guy he forwarded it to: never checks his email. Ricky Coates Maintenance Safety, huh? I run around this place all day trying to keep things safe. This building, it ain’t old but it ain’t so new, either, you know what I mean? There’s a lot of upkeep just holding it together. Here’s a good example: the utility stairs in the back area? No residents ever use them, so you’d think there’s no safety trouble. But staff use them plenty, and over the years the treads on the stairs get worn down. Little by little, they get smooth and slippery, and suddenly you have a problem. That’s where I swoop in. Or the boiler. Don’t get me started on the boiler! That thing’s so finicky. Probably should have been replaced five years ago, but it’s a big expense, so we keep fussing with it to keep it together. I’m always down there trying to hold it together with chewing gum and bailing wire. I got all that stuff to deal with – and a thousand little things like that every day, stuff like doors getting sticky, railings that are loose, you name it – and they want me to take time to check my email. Email! I got no time for that. I’m no good with computers anyway. You want me to stretch out the life of a boiler that ought to get taken out behind the barn and shot, I’m your guy. But messing around with computers? I’m hopeless, even if I had time for it. Which I don’t. Joseph Cobb Maintenance You’re here from the central office to talk to us about safety? I got nothing to report. Everything’s fine. No, really. No comment. If somebody tells me they know about something that isn’t safe, I fix it. It stays fixed. That’s my safety plan. If something’s broke, fix it. OK, you know what? I can think of one safety problem I had. Couple of years ago, right after I started here, we had this busy afternoon, oxygen supply system ran low. Guy who was training me in got asked to go hook up a new tank. We grabbed one and wheeled it over to the system. Went to hook it up and the fittings didn’t match. I said no big deal, it’s a bum tank, we can pop the fitting off of the old one and put it onto this one and be good as new. We were halfway through doing that when a nurse walked by, asked us what we were doing, and blew her stack when I explained. She pointed to a label that said the tank was full of argon, not oxygen, and it’d been stored in the wrong place! Then she told me that the different fittings thing was on purpose, to keep the tank from getting accidentally hooked up to the wrong system. Hoo boy, did my gut drop. That would have been a nice thing for someone to have told me ahead of time, you know? Faaiso Maslah Housekeeping I have many concerns about safety here at Clarion Court. I know that my fellow workers care very much about safety. But we are so busy all of the time! Safety is a thing that takes time and care, and we do not always have the time to take care. I know that there is a safety plan in a binder in the back office. But it just sits in that binder unless it is time for new employee orientation or special refresher training. They tell me that the Fire Marshall has a rule that our hallways must be a certain width, and that they must have no obstructions so that people could escape the building during a fire. But I see again and again, things – large things, like beds and wheelchairs! – left in hallways, blocking the way. I know that these things are just meant to be left for a moment while a person deals with something else. But then a new problem arises, and they move on. To be honest, I am nervous about talking to anyone about this, because I do not want the nurses to feel like I am informing on them. I do not want to make anyone angry or land anyone in trouble! I just want to follow the rules as I have been told them. It also seems to me that some of the nursing staff do not like each other and will not listen to each other. Some of the RNs with more education do not think much of the CNAs who do not have much education, and the feeling goes both ways. This means that information does not flow from one person to the next, and that people do not ask for help when they perhaps should. Anne Marie Kelley Dietary Staff Thanks for talking to me! Nobody ever thinks to ask me about stuff like this. Which, hey, that’s a problem. We got safety issues in food service like you wouldn’t believe! Most of it isn’t anything special to us – people just don’t think about all the risks you get with a big institutional kitchen. But come on – just basic food handling’s a big, dangerous area where you have to be really careful. Somebody gets sick because a worker at a burrito place didn’t wash their hands after going to the bathroom, that’s bad. Somebody’s grandma with a weak immune system gets sick because a worker here got sloppy, that’s a million times worse. Or think about spills. Not a thing you can prevent, really. All you can do is try to spot them and get them cleaned up as fast as possible. But jello on the floor, that’s pretty slippery, and some of the residents aren’t so steady on their feet. Actually, it’s not just food that causes slipping trouble. I know this sounds gross, but we have some residents with continence problems, and that can be pretty slippery, too. Here’s one for you… I happened to see on the news the other day that there was a food recall on some hummus, it had E. coli or something. The name sounded familiar, so I came in the next day and looked- sure enough, it’s the exact stuff we serve! I pitched it and told my boss. Couple days later, she walks up all mad… She said she she’d told Stephen Silva, the administrator, about it, and he got all apologetic and said that he’d heard about the recall but forgot to pass it on. He said nice things about me catching it and taking action, and that’s great, but I’m still pretty ticked why couldn’t he have just passed along the word? I don’t know. I do my best to follow the rules in my little world. But I can’t do much about everybody else, you know? Reflection Questions Per Stephen Silva’s request, what is a potential area of concern to target for improvement? This question has not been answered yet. What are some potential evidence-based strategies that could be used for this improvement? This question has not been answered yet. Conclusion Congratulations! You have completed this activity! .