Patient basic safety is the foundation natural stone and one of the central concerns in quality improvement for the health care establishment. Keeping our patients safe is a challenging issue because errors and problems can and do arise any time. Individual error is inescapable, reducing mistake and minimizing the consequences of error is best achieved by learning from mistake, somewhat than blaming frame of mind. Over the years, nurses have assumed functions in various quality improvement and health care risk management activities. Learning from errors and close to misses really helps to provide opportunities to get over system gaps, design alternatives and modify management systems can reduce the chances of future errors preventing disaster.
According to U. S Company record (2001) patient safeness practice is a kind of process or structure whose request reduces the probability of adverse events caused by exposure to medical attention system across a range of diseases and steps. The Institute of Remedies (IOM) reported that between 44, 000 and 98, 000 patients expire in hospitals placing in 1997 in the United Talk about of America (USA) each year therefore of health care errors which include, transfusion of incompatible bloodstream products, medication errors, foreign objects still left in body, equipment failures, mistaken identities of patients or areas of the body. These errors took place at any stage of medical care and attention delivery system, errors with serious repercussions were observed in most vulnerable specialized medical settings. Section of health (2001) An Australian review reported adverse event rates of 16. 6% which 13. 7% led to permanent impairment (Wilson, 1995).
The Institute of Remedies (IOM) released (2001) a report on 'To Err Is Individuals: Building a Safer Health System" Based on two research studies: one conducted in Colorado and Utah discovered that 6. 6 percent of undesirable events resulted in death, as compared with another research conducted at NY, found that negative events occurred in 13. 6 percent in New York hospitals. In both of these studies over one half of these adverse occurrences resulted from medical errors and could have been prevented. When extrapolated to the over 33. 6 million admissions to U. S. nursing homes in 1997, the results of the study in Colorado and Utah imply that at least 44, 000 Americans die each year therefore of medical mistakes. The results of the New York Study concluded that deaths due to medical mistakes exceed the number attributable to the 8th leading reason behind death.
Scenario
During my scientific experience, I came across a situation where I received call from medical center incharge and reporting one sentinel event, group of e-mail exchanged and on call administrator requested me to terminate designated staff who do an error. I've utilized my management knowledge and skills to the best of my understanding. The circumstance was an 11 years old boy (Patient A) presented to hospital with the complaint of fever, headache and vomiting. 40 years obstetrics (Patient B) was accepted through emergency office for induction of labour. Both Patients' bloodstream was set up and both have different blood groups. At night medical professional order to transfused blood vessels to Patient A. Assigned nursing staff visited the lab with accurate transfusion request slip and blood releasing form but however Patient B blood pack was picked rather than Patient A from the bloodstream refrigerator at laboratory. Blood examined by same nurse with on call given medical professional before transfusion but again failed to check for accurate id at the foundation side. Transfusion began to Patient A at 0700 time. Shift improved at 0800 time, over extracted from night personnel with bloodstream transfusion but again confirmation was not done because of this unrecognized transfusion reaction occurred and finally Patient A expired at 13:00 hrs.
I have looked into the truth and requested respective given team and stake holders for real cause analysis. The problem was very unpleasant and challenging as an eleven years of age child died due to error but it gave me lots of possibility to identify the system gaps in order to avoid from re-occurrence in future.
As a management position, I wanted multidisciplinary team to do the primary cause analysis. Real cause analysis is a process for determining the factors that underlie deviation in performance, like the occurrence or possible event of an sentinel event. A real cause analysis focuses generally on systems and techniques, not on individual performance. The evaluation advances from special triggers, clinical operations, organizational functions and systems, identify potential advancements in these processes or systems.
After does a root cause analysis the occurrence was classified as sentinel event. A sentinel event can be an unexpected occurrence regarding death or serious physical or internal injury, or the chance thereof. Serious harm specifically includes loss of limb or function. Such occasions are called "sentinel" because they indicate the need for immediate inspection and response. Sentinel occurrences are recognized under the Joint Commission on Accreditation of Medical Organizations (JCAHO) and emphasized those regulations helps organization to develop precautionary measures. (The Joint Commission payment, 2011).
The Joint Payment on Accreditation of Healthcare Organizations (JCAHO) has positioned considerable focus on promoting patient safe practices through a variety of mechanisms, like the reporting and research of sentinel happenings that can lead to modifications and advancements in policy and practice within healthcare settings. We must apply the same ideas learnt from our experience.
When a sentinel event occurs in a healthcare organization, it's important that appropriate individuals within the business be familiar with the function, investigate, understand the causes that underlie the event, and make changes in the organization's systems and procedures to reduce the probability of such an event in the foreseeable future. As a key management position it is my prime responsibility to work as a team with multidisciplinary way, take as an opportunity to increase the system and ensure the compliances of the establishment policies and process by nursing division. An organized strategy for identification, analysis and evaluation of risks and the devising a plan to diminish the event of accidents, situations and incidents (Sullivan & Decker, 2000).
The Institute of Treatments has designed six aims for bettering the delivery of care and attention in the United States which includes; Safe, effective, useful, well-timed provision, equitable and Patient focused approach to be able to provide safe and quality healthcare services. (Institute of Treatments, 2001).
According to Pelletier and Beaudin (2004) The Institute of Treatments defines healthcare quality as the extent to which health services provided to individuals and patient populations improve desired health outcomes. The health care should be based on the strongest specialized medical information and provided in a theoretically and culturally proficient manner with good communication and shared decision making.
During real cause analysis I came across a lot of areas that was identified for regions of improvement that, authority needs to provide resources to be able to provide quality services as data by provision of resources was absent in laboratory which resulted that in night time shift staff visited receive bloodstream by herself no check and balance of patient identification was done. However, it is not clearly described in the insurance plan that what will be the mechanism of check and balance at laboratory end. At secondary hospital lab services timing is from 0800 time to 2300 hours, but imagine if need comes up after wards. It was used as a granted that services won't require in night timings. Furthermore, it was not clearly defined in the bloodstream transfusion coverage which defines the first steps of checking out blood for accurate identification at laboratory level. Regarding to Daniel (2004) Clinical Management identifies medical diagnosis, treatment planning and delivery and guaranteeing the correct id of every patient and technique. As a nursing departmental heads the need was identified to examine the insurance policies and procedure, organized quality confidence program and Total Quality Management system (TQM) is necessary in order to prevent from reoccurrence. TQM is a management beliefs that emphasizes a committed action to excellence throughout the organization (Sullivan & Decker, 2000).
Total Quality Management (TQM) is a sub-discipline of management science which handles the problem of standardization and augmentation of organizational performance.
According to Khan (personal communication November 20, 2012) research was completed in 2006-2009 by for critical evaluation of TQM implementation in Pakistani organizations located on physical basis. This analysis explores the factors influencing the success and failure of the TQM program in the organizations. It particularly explores how these programs work within the context of various organizational information, dynamics and culture. The analysis found that TQM execution is heavily reliant on various factors related to organizational framework and culture. It also identified that the end results and changes expected by organizations from TQM implementation aren't only dependent on its own framework but on a great many other cultural related 'intermediate effects'. These intermediate influences are mostly related to organizational dynamics and culture and are dismissed in the majority of the firms, resulting in early failure of TQM. Based on the findings of the research and the working experience of employing TQM in several organizations, the author also proposes a fresh platform of TQM implementation named as MSAC routine i. e. Mobilization (trial phase), Standardization (Short-term period), Acclimatization (mid-term period) and Culturization (long term stage). This analysis and the suggested TQM implementation platform is quite valuable for the organization who are presently utilizing or desirous to put into practice TQM more effectively and efficiently.
The Aga Khan College or university Hospital started out its procedure in 1985. Basic quality confidence methodologies were introduced and from 1994 onwards, the constant quality improvement (CQI) model of AKUH fostered a good culture of change by building a lot of core quality activities across the clinical and managerial disciplines; which include, quality circles, basic quality control tools, education and training in quality, monitoring of quality indicators, health care specialists credentialing, Patient issues, Patient satisfaction, morbidity and mortality reviews, nursing quality assurance program and quality grand rounds. Finally in 2006, AKUH received the platinum seal of international accreditation in health care by the Joint Percentage International Accreditation (JCIA) with the unique distinction to be the first medical center in Pakistan and among few colleges based hospitals in the world to get the quality recognition. AKUH is now on the enlargement and integration phase of its quality voyage, the central traveling force towards its quality perspective is improvement of operations and results and achieving a solid "customer orientation" towards both exterior and internal customers. This can be achieved through focusing on the goals and strategies of a healthcare facility and all its departments to these three major topics that is improvement in quality of attention, services and cost-effectiveness. It really is more popular that quality indications or performance signals can give a very important insight into the quality of care and attention being provided to patients.
Performance signals are best way to learn and improve, but to instill ownership in the center of every person is the main element to having important indications. Thus making performance indications a part of a physician's and medical performance analysis not only ensure that they actively participate in bettering their own performance, but also ensure that, quality of attention provided to the patients is definitely and continuously bettering. In this professional medical situation I also participated in expanding the procedures with multidisciplinary team and tool in order to regulate quality system and also to evaluate the compliances of practice for sustainability. Fostering a culture of basic safety requires more than producing new guidelines and procedures. Developing a culture of protection requires critical thinking, problem solving, risk id & management and human being factor training. The relevant books and websites on patient security program has recommended many protection related performance indications and systems of check and amounts which can ensure patient's safety during patient's stay at hospital. A organized and multidisciplinary procedure is, therefore, very imperative to pick-up medical problems and devise strategies to reduce them as it defiantly takes on an important part in patient safety.
Literature Review
The books review will treat overall idea of patient safety and its related issues and concerns, international perspective of problem occurrences, protection related performance signals and measures to build positive basic safety culture. Several studies are carried out on measuring and assessing patient safety and final results at several healthcare organizations (Baker 2003; Arah, 2004; Colla, 2005; & Karsh, 2006). Matching to Colla (2005) Accomplishment of a culture conducive to patient safeness may be an admirable goal in its right, but more work should be expended on understanding the relationship between steps of safety environment and patient benefits.
The Luxembourg Declaration on Patient Basic safety (2005) has witnessed that medical sector is a high-risk area because negative events, due to treatment alternatively than disease, can result in death, serious damage, problems and patient suffering. Although many hospitals and healthcare configurations have techniques in place to ensure patient safety, the health attention sector still lags behind other companies and services that contain introduced systematic basic safety processes.
Almost fifty percent of joint commission payment standards are directly related to safety, addressing such issues as medication utilization, an infection control, surgery and anesthesia, bloodstream transfusions reactions, personnel credentialing, fire safeness, medical equipment, devastation management, risk recognition and management, sentinel event monitoring, security and safety structures. These specifications address lots of significant patient safe practices issues, including the implementation of patient protection programs; the response to adverse situations when they take place; the prevention of accidental damage through the prospective evaluation and redesigning of vulnerable patient systems and it's really the organization's responsibility to clear and take possession and accountability.
Agency for Health Research and Quality (AHRQ) records (2001) has advised the same that to examine guidelines from scientific literature, Redesign care predicated on guidelines through collaboration of multiple departments, Evaluate technology solutions, Put into action performance measurements and Monitor selected measurements and present conclusion reports to senior leadership. Moreover, the Advisory Mother board Research document helps the kind of error mentioned in the AHRQ 2000 information that the most common mistakes per 1, 000 appointments are: 65 happenings per due to adverse drug events, 60 occurrences due to hospital acquired infections, 51 happenings related to procedural problems and 15 situations related to falls.
Besides analyzing the common errors in terms of patient safeness, Mrayyan and Huber (2003) talked about three areas of patient protection issues. First is worries that is whenever any unfortunate incident happens and it is publicized; it generates fear and apprehension among team members. Second issue is errors as a system problem, that involves repetition of same kind of error that will require close and immediate interventions. Third is the hyperlink between mistakes and insufficient resources which means inadequate number of staffs or inadequate trained staff that can jeopardize patient safety.
The medical mistake and harm to patient safety does not only let the patient suffer but brings a direct effect on society at large. The Danish Society for Patient Safeness (2005) discussed the consequences that adverse occurrences can have on patients; health care personnel and population at large are significant. Patients may are affected both actually and psychologically from sufferings created by the harm itself, but also by the way the event is handled. Health care employees on the other palm may experience pity, guilt and depression, with litigations and claims imposing an additional burden. Society at large suffers from less quality of life of its customers, with associated extra healthcare costs but also costs the effect of a lower production of the population.
After root cause analysis I also felt that it is necessary to have interaction an example may be to 1 basis to relevant healthcare personal who performed an error to be able to sensitized them and mentored through education way somewhat than terminating the worker, give them insight that the would be the future ambassador for patient basic safety because, I personally believe that quality echo when person itself ready to take action, it should be our constant determination towards company that patient basic safety should be our top priority, which infuses the entire organization, for that it is compulsory that first we should acknowledge the problem then promote blame-free environment where folks are empowered to record errors without the fear and abuse so they can willingly address security concerns.
Daniel (2004) talks about that, what can be done today to improve patient protection while were waiting for facts on effective interventions. First, we need leaders those at the top of organizational graphs as well as leaders whatsoever level, second, we have to focus on detailed systems of protection rather than attempting to address safety one problem at a time. Three elements comprise comprehensive patient safety: active case finding, methodical research, and system redesign.
Patient protection initiatives and programs change from institution to organization but the goal remains the same that is lowering mistakes and promote basic safety. Klazinga and Arah (2004) said "it is noticeable that current efforts emphasis too narrowly on the individual with little explicit linkage to wider areas of health system basic safety. Risks management includes reducing harm not just to patients but also to staff, visitors and the surroundings including population".
Some of the individual protection alternatives and alternatives suggested by Mrayyan and Hubber (2003) are emphasizing on building up system of mistake reporting and correction that is error detection and reporting system within business to reduce medical error, patient education in all respects of treatment and making use of risk management skills by healthcare personnel. In addition, creating an information system and building facts bottom for patient security, examining the impact of various management procedures like staffing, increasing of medical mistakes and high risk people and monitoring error rates with necessary actions can reduce medical problems and also use of information technology could work towards improving patient safeness. Besides all of this, dedication of the doctor to reduce errors and promote basic safety in any group enhances protection not limited to patients but also for the healthcare personnel and society in general.
This position paper related to sentinel event also offers me insight to execute a self-reflection of my job related competencies as a key management representative. Personally, i think that, Knowledge can be achieve by reading books but the art work of utilizing that knowledge and skills gives confidence to fulfill job in an efficient way. Corresponding to (Barker, Sullivian & Emery 2006). express three key functions organized directly into three categories called social roles, informational tasks and decisional tasks. In interpersonal assignments manager has lots of job tasks in order to full fill organizational goals, informational roles comprises of screen and disseminator as that administrator is the focal person and considered an as nerve middle. Third category is decisional functions which consist of entrepreneur, disturbance handler, source allocator and negotiator. The first two categories are related to day to day operation However, the third category need that how manager use his/her competency in clear direction which meet up with the organization eyesight and quest.
Integration of Model
There are amount of the clinical theories and models about the human error are discussed in management. Among that i have chosen the Eindhoven style of incident causation.
Eindhoven Model of Incident Causation:
This model was formerly developed to identify root factors behind safety related occurrences in the Netherlands and has since been analyzed in commercial and healthcare settings. The Eindhoven Style of incident causation recognizes three main factors behind error: individuals operator, organizational and specialized inability. These failures, together or in combination, are through accountable for reinitiating a chain of events which may finally lead to a detrimental patient outcome. In performance improvement terminology, such failing would be considered the primary cause of an incident. According to the model, risky situations will develop into incidents if inadequate system defenses can be found to remediate the problem. The Eindhoven Model of Incident Causation offered as the theoretical basis for expanding the Eindhoven Classification Model, which has since been adapted for the health care website (Jacob & Cherry 2011). This classification model boasts that errors arise either because of effective failures or latent conditions.
Human Operator Problem: (Productive failure):
Human operator errors are those made by individuals at the 'sharp end' by health care workers. Also, they are known as active failures or dynamic errors. Active failures fall under three major categories; skill based, rule-based or knowledge-based. Skill based mostly error arise when a person makes one through the performance of your routine task that will require little conscious work as facts by its routine practice of nurses to bring bloodstream from lab or its routine to consider daily over from forthcoming shift but in different intervals but nurse fails to check for appropriate identification with patient name and medical record quantity. An example of a skill centered error would be a nurse forgetting to drive the 'start' button with an IV pump after priming the tubes. A rule founded mistake occurs when a person does not perform a procedure or protocol properly or chooses the incorrect procedure just as this sentinel event nurse and medical doctor fails to compliance with procedures and procedure because of this wrong blood was transfused. A good example of a fuel-based error is a phlebotomist failing to check the patient's recognition before obtaining a blood specimen. A knowledge based error identifies the conscious but incorrect software of existing knowledge to a fresh situation. A good example of a knowledge-based problem would be when first patient develop fever or sign of response she needed as an granted and stop blood for time being neither nurse or doctor utilized their knowledge and included theory directly into practice or critically assess that what will be the possible reasons for fever. Human mistakes have typically been the emphasis of traditional occurrence report monitoring because they are more obvious that latent conditions. Even though some of the factors resulting in human problem are amenable such as knowledge deficit, staffing shortages, work over insert etc.
Technical or organizational error (Latent Condition/ Latent problem):
Technical and organizational errors are referred to as latent condition or latent errors. Latent conditions result from sanctions or decisions created by administrators or others in command positions that affect technological issues, organizational plan or the allocation of resources. These problems are called latent due to delayed and unintended effects that may have an effect on patient basic safety at a later point. Tech error occurs when there are problems with equipment, forms, brands, etc. (e. g. your computer does not print patient identification brands regularly). Organizational mistake can be related to various, often complicated issues involving management priorities and organizational culture. An Example of a latent mistake would be an organizational decision never to use a computerized professional order admittance system which results in a high amount of medication problems related to illegible handwriting.
Other Problem (Unclassified):
A third category in the Einhoven Classification Model accounts for errors that can't be classified as lively or latent. In healthcare, such errors are generally due to patient-related factors that donate to error, for illustration, if patient offered the history of allergy and this can lead to potential medication problem. One whose cause cannot be placed in virtually any category (i. e. latent, energetic, or patient-related) is termed unclassifiable.
In order to ongoing quality improvement and promote patient security culture it's important to market culture of reporting of errors is the first step along with a constructive process towards knowing that what factors within something enable one to occur. This systems methodology is gaining earth and many medical center administrators have become well versed in its theory and practice. To market a 'culture of protection' the command of an organization promulgates an atmosphere in which the reporting of errors is welcomed, so that others may benefit from knowledge of the situation and can form strategies predicated on the data. A major element of this framework is a non-punitive position towards the average person who records or who have in an incident. In a very just culture a business lets its employee know that they will not be disciplined to make faults and that the leaders value the importance of learning from mishaps and seek to increase the system that allowed them to occur.
Recommendation
Based on sentinel event that i address in my position newspaper and in light of literature, I would like to recommend few ideas/ tips to enhance our quality system. First to be able to market in healthcare organization, major emphasis required in order to set-up non-punitive environment where health care workers can article events, errors and near misses without fear of reprisal or disciplinary action. Next, the chance management website should be organized at organizational level where relevant multidisciplinary key stake holders should recognized in order to have possession and facilitate clinicians and organizational managers at all levels, the to be able to create such an atmosphere which helps bring about patient security culture within an organizations. Must develop and put into practice a reporting system that motivates and enhances reporting by all office and staff. Inform all clinicians, personnel, and management personnel on the nature and importance of the event confirming process, including disclosure and discovery issue. Needs to do timely and accurate documents of sentinel happenings help organizations enhance their protection and quality of care and attention and learn from other organization's unforeseen benefits, which allow other healthcare organizations to understand the likelihood of certain sentinel occasions, thus giving staff enough time and knowledge to build up ways of avoid these occasions before they actually happen. Utilization of event article data to pattern and analyzes organizational risks and distributes these details to appropriate staff of the organization so that risk-prevention steps can be developed and carried out. Finally provide clinicians and personnel ongoing feedback on their risk-reduction attempts, results of event reporting should be mentioned at the departmental level, and type on corrective actions/process improvements should be solicited.
Conclusion:
In conclusion, I must say that errors may appear at any point in the health treatment delivery system. Acknowledging that errors, learning from those errors, and working to prevent future mistakes represents a significant change in the culture of health care, a paradigm shift from blame and punishment to evaluation of the main causes of errors and ways of improve systems and operations by applying patient safety measures which offer an objective, validated strategy for discovering Potential Security Issues.
Management should try to break down obstacles by implementing non-punitive cultures predicated on industry guidelines. This may sheds new light on traditional options for removing reporting obstacles, develop employee determination to identify and report errors or event occurrences. Once the staff proactively participates in reporting, the reporting process becomes a car for making tactics improvements in the delivery of patient health care and management gets information that in any other case would not be available. As one director said, if no person reports it, you do not know. When some occurrences are not reported, management gets limited information which to base their decision. It goes without saying that better data mean better decisions.
According to Daniel (2004) " the goal should be not only to increase the number and quality of information but also to increase their usefulness as rich sources of information for the technology of strategies strategies aimed toward medical-error reduction" (p. 27). Matching to Minesota Alliance for Patient Security (2005) safeness culture is not blame-free strategy; it can be an approach that amounts the need to promote open up reporting and the need to hold practitioners in charge of their behavioral choices. Nursing homes should identify potential safety issues, having proactive methodology, solution baseline performance, and arranged priorities for process improvement initiatives. Using this methodology, hospitals can execute patient protection program with minimal investment on the part. Informational reviews can be produced and disseminated to proactively identify safe practices issues and drive advancements for the better health care outcomes.
