Identifying Areas That Expose Hospitals Essay

Over the last several years, a wide variety of health care organizations have been facing a number of challenges. This is because of pressures associated with: rising costs, increasing demands and larger numbers of patients. For many facilities this has created a situation where patient safety issues are often overlooked. This is because the staff is facing tremendous amounts of pressure, long hours and more patients. The combination of these factors has created a situation where a variety of hospitals need to improve their patient safety procedures. In the case of Sharp Memorial Hospital, they are focused on addressing these issues through different strategies. To fully understand how they are able to achieve these objectives requires looking at: specific ways the organization has responded to the crisis in medical errors, their definition of patient safety, the causes of errors, systematic barriers and transformations that have been adopted. Together, these different elements will provide the greatest insights as to how the facility is coping with the crisis in patient safety.

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

The term “safety comes first” or more simply put, “safety first,” is a message that patients not only want to hear, but also want to know is the focus of the professionals that are caring for them; in particular, when they are under anesthesia and have limited or no ability to speak up or lookout for themselves. The National Patient Safety Agency (NPSA) has implemented two initiatives; Rocognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients (NPSA, 2007) and How to Guide: Five Steps to Safer Surgery (NPSA, 2010). Understanding that human beings make up the healthcare professional workforce, it is evident that tools and checklist can and will only be as good as the how people utilize and follow

Patient safety is of major concern in healthcare settings due to the preventable nature of events that sometimes lead to serious injury, and even death, for patients. This was catapulted to the forefront of healthcare delivery in 1999 when the Institute of Medicine wrote a scathing report; To Err is Human: Building a Safer Health System, that highlighted "the lack of safety for patients in healthcare organizations" (Ulrich and Kear 2014). The National Patient Safety

The cost of Medical equipment plays a significant role in the delivery of health care. The clinical engineering at Victoria Hospital is an important branch of the hospital team management that are working to strategies ways to improve quality of service and lower cost repairs of equipments. The team members from Biomedical and maintenance engineering’s roles are to ensure utilization of quality equipments such as endoscope and minimize length of repair time. All these issues are a major influence in the hospital’s project cost. For example, Victory hospital, which is located in Canada, is in the process of evaluating different options to decrease cost of its endoscope repair. This equipment is use in the endoscopy department for

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

Equipped with the knowledge of how the WHO surgical checklist minimises the risks of adverse surgical incidents, I am keen in the performance of these safety checks. As Perry and Kelly (2014) highlighted, the WHO surgical safety checklist has heightened the understanding and focus of surgical safety, thereby, I try to do it habitually so that I will be

The World Health Organisation (WHO) implemented the surgical safety checklist, to minimise the discrepancies that occur as a result of improper identification of the patient (appendix O post 3). Improper identification leads to wrong procedure, hence complication and possibly death (Position Statement Surgical Safety 2015). The WHO checklist helps to improve surgical safety through confirming safety practices are upheld and developing better communication within the multidisciplinary team (Position Statement Surgical Safety 2015), thus providing optimum patient care (ACORN Competency standard 5). Surgery related complication and mortality was reduce by 33%, through a study of eight hospitals from 2007 to 2008 (Position Statement Surgical Safety 2015). Therefore proving that compliance with safety measure were increased as a result of endorsing the SSC, and obliges to competency standard 3.3. Through briefing and debriefing, standard of care is improved, as the whole multidisciplinary team is made aware of the procedure, and allows for optimal performance, which decrease surgery time, thus improve surgical safety (ACORN Competency Standard 9). Furthermore it is important that each hospital adapt their own policy in regards to the type of facility, such as in the occurrence of near miss episode (appendix 1,), institutions must refine their policy to provide the best care for the patients (Position Statement Surgical Safety 2015).

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

The quantity of surgical procedures performed annually is immense and increasing. Surgery is associated with considerable risk of complications and death, however many of these complications are preventable. Haynes et al (2009) published an article in which they formulated, implemented, and evaluated a surgical safety checklist with the hypothesis of reducing the morbidity and mortality of surgical patients (Haynes et al., 2009). The checklist was aimed at improving team communication and consistency of care. They theorized that recurrently checking a specific list of elements would improve the functionality of the operative team, and reduce preventable errors. This analysis is designed to identify the goals, methods, and results of the program to establish its overall feasibility, functionality, and limitations.

The concern with not educating trainees before graduation is that incident and near misses tend to remain underreported because of the perpetuating negative culture surrounding error reporting. This in turn hinders learning from the event and stifles growth toward voluntary sharing of broken processes and system failures (Barnsteiner, 2011). The current focus on Quality Improvement is to provide high reliable care with little to zero risks by including the “combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development” (IHI, 2015).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

In the operating theatre, upholding and promoting a safe environment for the patient is of utmost importance. Perioperative nurses can contribute to this safety culture by their participation in the surgical checklist. In Australian hospitals, the surgical checklist that is implemented in the theatres is an adapted version of the World Health Organisation’s surgical safety checklist (Kim et al., 2015). The checklist complies of 3 main phases and 19 elements to be checked. The phases occur before the induction of anaesthesia, before skin incision and before the patient leaves the operating room (Kim et al., 2015).

History of patient safety culture: Patient safety culture, this concept appears to be a new but it was found that it existed long before. In the 4th century, Hippocrates had known that well intentioned action of healers can cause harm. (1) in 1987 the term of safety culture first appeared in the international nuclear safety advisory group (INSAG) report as a result of the 1986 Chernobyl disaster.(2) Since then safety culture became more recognizes and patient safety culture appeared in 1999 with the introduction of reporting of medical error “to err is human”: building a safer health system by the institute of Medicine, patient safety became more recognized and a prominent topic recently. The report shows that 44000 to 98000 deaths each year are from medical mistakes in United State hospitals and recommend as top priority to adopt the error reporting system and to create an environment in which culture of safety is a goal.(3) The media coverage of the report was widespread resulting in a sudden public awareness of the problem.