How Virginia Mason Was Saved.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

Providing the best care to each patient starts with providing the proper amount of staff members to each unit. Looking at the needs of different units not only allows administration to see areas for improvement, but also areas that are being handled correctly. Utilizing the indicators provided by The Joint Commission, 4 East, a pediatric medical/surgical floor, has a high rate of falls and nosocomial pressure ulcers that appears to be related to the increase overtime nurses have been working for that floor (Nightingale, 2010). Research has shown increases in adverse events have been related to nurses working over 40 hours a week (Bae, 2012).

TPS was not the first production model to be imported into the health-care delivery organizations. For decades hospitals had tried several management models drawn from production industries such as Total Quality Management (TQM) and Six Sigma. VMMC has previously utilized TQM in the 1990s, but the concepts had failed to gain traction.

Patient falls in hospitals continue to be a major and costly problem. The definition of a patient fall is an unplanned descent to the floor, assisted or unassisted, with or without injury to the patient. The authors of this article wanted to investigate the effect “missed nursing care” has on patient fall rates and patient outcomes. The authors also looked at hospital staffing as it relates to patient falls and nursing staff having enough time to carry out all nursing responsibilities.

In addition, high risk participants received education relating to falls which involved nurses instructing participants not to get out of bed without assistance, to press the call-bell for assistance and how to use the call-bell. As part of this study protocol, participants in the intervention group received usual care which include: fall risk assessment, placing the call-bell, TV remote control, eyeglasses, dentures, and hearing aids within the patient’s reach. Other interventions that have been used were bed and chair alarms, bed was in the lowest position at all time except when care was being provided and bed brakes were locked at all times. The patient’s elimination needs were scheduled every two hours, bedside commode was provided for frequent elimination needs, the patient was not left unattended while on bedside commode or in the bathroom. For a safe bathroom environment toilets was raised, toilet seats were secure, and handrails was strong enough to support patients, and patient was also instructed to pull the call light if feeling dizzy or in need of any assistance . Furthermore, the room temperature was

Despite the challenges, this facilitating experice has instilled me a degree of appreciation of many staff who work hard behind the scene to ahcieve the common goal of providing the best care possible to patients within the scarce resources. It was possible to see how good working relationship with other disciplines can improve overall efficiency.

In the healthcare system, Core Measure sets are used to measure quality care. It consists of pneumonia, heart attack, immunizations, emergency department, sepsis, for infection prevention, and others. Evidence-based treatments are used to prevent occurrences using structures, processes, and outcomes. In nursing, they have adopted a similar method of performance measures, known as nursing-sensitive indicators. It includes falls, and this indicator is implemented in each unit of the hospital and managed by the manager and educator along with others like CAUTI and CALBSI. According to the American Hospital Association article (2015) “Falls with Injury,” Patient falls-an unplanned descent to the floor with or without injury to the patient affects between 700,000 and 1,000,000 patients each year.”

Moreover, the office visit length will be shortened due to the high demand of customers making it harder to provide good quality of care to patients as well . On the other hand, from the physician point of view it is predictable that doctors will change practice patterns from private offices to hospital services because the facilities pay salaries with less expectations in the number of patients seen per day. Furthermore, due to the elevated number of patients, time left for clinical documentation and record keeping will be nulle.

Bedside report has also become a critical component to maintain patient safety. In the past nurses would give hand off report at the nurse’s station, leaving their patients alone. This time frame has proven to be when the majority of sentinel events occurred, such as falls (Ofori-Atta, J., 2014). Bedside report keeps patients involved in their care and reduces the risk of errors in communication between nurses and maintains patient

Keywords: Clinical Supervision Patient Safety Quality of Care Nurses Risk of Fall Morse Fall Scale

Quality improvement is referred to as “the use of data to monitor the outcomes for care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care” (Sherwood & Barnsteiner, 2012). Data is used as the reflection of quality care that is provided by nurses and presents whether or not improvement is needed. In order for nurses to be mindful of the care that they give, they must be taught a systematic process of defining problems, identifying possible causes of those problems, and methods for trying out new solutions to prevent those problems (Sherwood & Barnsteiner, 2012). Currently, quality improvement measures are being utilized throughout hospitals to reduce the risk of patient falls and fall injuries.

This option has great potential for generating patient retention and referrals due to DHC paying attention to patient’s requests increasing their loyalty and people willing to attend DHC opposed to the new clinic. Although this alternative would increase patient’s visits, profitability is not a guarantee. This option would also require an increase of 33 percent in personnel costs and cost of the other physician.

A reoccurring issue such as bedsores is something nursing home facilities try their best to prevent. Unfortunately, the rate at which it is occurring in our nursing home is 12%, a little higher than that of the national average. This is a number that we as a facility are not proud of, and as Director of Quality Improvement, new strategies will be implemented to improve the quality of care in which our patients are receiving. This simple plan mimics that of the FOCUS PDSA and can be broken down into a few steps in order to be better assessed. The first step involves creating a team of employees to research and better understand the main source of the bedsores. The second step includes developing a strategy, without any errors, within the team

Issues related to a lack of patient safety have been going on for a lot of years now. Throughout the first decade of the 21st century, there has been a national emphasis on cultivating patient safety. Patient safety is a global issue, that touches countries at all levels of expansion and is one of the nation's most determined health care tests. According to the Institute of Medicine (1999), they have measured that as many as 48,000 to 88,000 people are dying in U.S. hospitals each year as the result of lapses in patient safety. Estimates of the size of the problem on this are scarce particularly in developing countries; it is likely that millions of patients worldwide could suffer disabling injuries or death every year due to unsafe medical care. Risk and safety have always been uninterruptedly been significant concerns in the hospital industry. Patient safety is a very much important part of our health care system and it really

One of the greatest challenges in healthcare, as well as the biggest threat to patient safety, is staffing and the nurse to patient ratio on hospital floors. Studies have shown that low staffing levels lead to increased mortality rates in patients, as well as multiple other adverse effects including falls and pressure ulcers. These adverse effects are all preventable, but policies on staffing must be in place to ensure safety for staff and patients.