Patient Safety And Quality Improvement Act: A Case Study

Over time the health care industry has become more complex. Health care is rapidly evolving and continuing to complicate our delivery of care, which in turn has the same effect on quality of care. This steady evolution and change results in nursing shortages and an increase in the prevalence of errors being made. In hopes of preventing these errors and creating safe and high quality patient care, with the focus on new and improved ways of thinking, The Quality and Safety Education for Nurses (QSEN) initiative was developed. The QSEN focuses on the following competencies: patient-centered care, quality improvement, safety, and teamwork and collaboration. Their initiatives work to prepare and develop the knowledge, skills, and attitudes that are necessary to make improvements in the quality and safety of health care systems (Qsen.org, 2014).

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.

Also enforced by OCR, the Patient Safety and Quality Improvement Act of 2005 (PSQIA) established a voluntary reporting system where data is analyzed and used to enhance the safety and quality of healthcare delivery. PSQIA provides confidentiality protections to healthcare providers who were previously concerned about the use of patient safety event reports in criminal, civil, and administrative proceedings. By limiting the use of event reports the fear report medical errors has decreased among many healthcare providers (Medical Errors and Patient Safety, 2008).

The Six Aims for Improvement and the 2016 National Patient Safety Goals (NPSG) are both guidelines for bettering and protecting the patient and their experience while being cared for in the hospital. In the book, Contemporary Nursing: Issues, Trends, & Management, it states that the six guiding aims should be accepted by every individual and group involved in the provision of healthcare, including health care professionals, public and private health care organizations, purchasers of health care, regulatory agencies and organizations, and state and federal policymakers (Cherry, Jacob, 2017, p.381). The NPSG clearly states its mission on its page. It says, “The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them” (2016 Hospital National Patient Safety Goals, 2015). Through this reflection of the guidelines, I will group them into categories and reflect on their meanings and how to implement them in nursing.

Back in 2003, the Joint Commission created a National Patient Safety Goal due to 23 occurrences of death or injury to a patient where alarms had been applied incorrectly or the alarms had been muted (Sendelbach & Funk, 2013). By 2004, Joint Commission had removed it from their National Patient Safety Goal list and made it a requirement for Joint Commission accreditations (Sendelbach & Funk, 2013). In 2013, it was brought to the attention of the Joint Commission regarding many alarm-related events, including multiple deaths, permanent loss of function, and prolonged hospital stays due to health care worker’s decreased response times to alarms (Horkan, 2014; Joint Commission, 2013). The Joint Commission reinstated a National Patient Safety Goal in 2013 and had requirements for all hospitals that had to be met by July 1, 2014 (Joint Commission, 2013). These goals included being able to make alarm safety a priority and develop a plan to decrease the amount of alarms. This plan could include preventing unnecessary patient monitoring, clarifying who is allowed to monitor and silence alarms, setting the cardiac monitors to have multiple tones, and having a brief delay in the alarm to see if the patient can self-resolve. The second phase of the Joint Commission’s plan was to be implemented by January 2016, to where the hospital must have followed through with their designated plan (Joint Commission, 2013).

The National Patient safety agency (NPSA) is an organization that created as a Special Health Authority. The function of this organization is to establish and managing patient in order to store maintain and secured semi-current records pending to their ultimate disposal. Besides that, the NPSA also assimilating safety-related information that can helps researcher to conduct research about healthcare. However, the security in accessing those records involves the authorization from the head of records agency that essential in protecting the patient records.

The National Patient Safety Goals are intended to assess the safety and quality of care provided to patients/residents. Of the programs created to provide quality patient care, two are in relation to this particular case, Nursing Care Center and Home Care.1

This paper, will discuss the National Patient Safety Goal NPSG 0.7.06.01 entitled “ Use proven guidelines to prevent infection of the urinary tract that are caused by catheter” (The Joint Commission, 2015). It will identify reasons why this National Patient Safety Goal was chosen as well as the type of organizations that utilize urinary catheters. It will look into financial implications of implementing educational process versus the hospital cost of Catheter-Associated Urinary Infections (CAUTI). The Advanced Practice Nurse (APN) will demonstrate method on how to gather data, design educational tool, implement standard practice and create a committee by collaborating with other health care discipline. Effectiveness of the educational process will be evaluated through data collection. Finally, future health care delivery implications will be explored.

In the United States alone there are 98,000 deaths per year caused by low quality health care (Ignatavicius & Workman, 2013, pg. 2). This statistic is disturbing because the errors that resulted in death were errors that were preventable. The intent of this chapter is to bring awareness to health care providers that are able to make a change in the quality of health care. In current practice patients are subjected to medication errors, preventable hospitalizations, premature death, and poor care provided due to racial, ethical, or low-income factors.

The National Patient Safety Goals were first developed in 2002 by the Joint Commission. The goals are established to help guide medical organizations to focus on which areas of patient safety need improving (Hudson 2016). The first set of goals were released and put in motion in 2003, prior to 2003 there were no policies or goals for an organization to set their sights on (Hudson 2016 page 2). A panel of experts advises the Joint Commission on the development of new goals or the updating of old ones. The panel is called the Patient Safety Advisory Group and is made up of nurses, risk managers, clinical engineers, and physicians (Hudson 2016). The National Patient Safety Goals have specific goals geared toward the type of medical organizations such as a critical access hospital, home care, behavioral health, and long term care services to name a few (Hudson 2016 page 2). The National Patient Safety Goals help protect patients and make sure providers are practicing safely across the board.

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

Patient safety which is the amount to which patients are free from unintentional injury has established a great deal of media attention during the past few years. Regulatory and professional agencies have specified that patient safety education should be given to healthcare workers to improve health results. The primary purpose of this essay was to gain a better understanding of the present status of patient safety consciousness among those that work in the health care setting... Risk Management Issue

Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis.

Patient safety is a critical part of quality care, and there is no question that how significant patient safety is. Every day we face several complex matters regarding patient care that forces us to think and act carefully. “Stories of patients having the wrong surgery performed, the wrong medication being administered, or dying from hospital acquired infections are too often the lead story on news programs” (Gomez, 2014). However, to bring down the percentage of safety risk, requires an organization that understanding and supporting a culture of safety in the workplace. Communication between the team is very crucial, also focusing on providing feedback on potential areas of concern help patient safety.

There are a number of situations that arise in healthcare every day and each situation is handled differently. “Patient safety is one of the most prominent healthcare challenges worldwide”(Brasaite, 2015). For improving health care it is important to share the responsibility for patient safety between all caregivers. Patients are often unintentionally injured as a consequence of their treatment; therefore, it takes many people to help an organization run efficiently and effectively. It takes teamwork, collaboration, coordination, and communication. Moreover, “patients arrive in the healthcare system trusting that the system will not harm them, but this may not always be true” (Brasaite, 2015). Ensuring the highest quality of care possible to all patients requires understanding and adapting care to the patients’ unique needs and perspectives. Only then can high-quality care be achieved in a patient-centered manner.