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Collaborate on Quality: Issue Analysis & Leadership Action Plan
Amie Griffin Date: May 2024
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Collaborate on Quality: Issue Analysis & Leadership Action Plan
The incident from the Vila Health Patient Safety simulation that I have chosen to analyze involves a medication error. In this scenario, the patient safety officer, Kyra, received a call from
the risk manager, Arthur, who reported a medication error involving a patient named B. Moore, born on 08/11/2005. This patient was located across the hall from another patient with a very similar name and birthdate.
In addressing this issue, I have several goals. The foremost goal is to ensure the patient receives the correct treatment, is safe, and is informed that corrective actions will be taken. Another goal is to implement measures to prevent similar medication errors in the future. Additionally, I aim to educate staff about medication errors, patient identification errors, and how such situations can be avoided. It is also important to inform healthcare employees about the
potential consequences of these errors.
A key factor I will focus on is inadequate staffing, a common issue in many healthcare facilities that can compromise patient safety and may have contributed to this medication error. Inadequate staffing can cause employees to feel rushed, overwhelmed, and stressed, potentially leading to mistakes like confusing two patients with similar names and birthdates. This situation might have arisen because the charge nurse, due to insufficient staff, was unable to avoid assigning the same nurse to both patients.
Moreover, I will address communication errors among providers, which could have led to confusion and incorrect medication being ordered. These issues underscore the importance of clear communication and adequate staffing to ensure patient safety and prevent medication errors.
Culture
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The culture within a healthcare organization encompasses its atmosphere, attitudes, behaviors, beliefs, and expectations related to its healthcare mission (Impact of Culture on Health Care, 2003). In such organizations, culture is a critical priority for ensuring safety and quality, as it influences how healthcare providers interact and prioritize patient safety. Based on my knowledge of the medication error issue, I believe this organization's existing culture demonstrates a strong understanding of patient safety and communication.
An evidence-based strategy to foster a culture of safety is to promote open communication and
error reporting. In this situation, it is crucial to communicate and report the medication error. By encouraging open communication and reporting, the medical team was able to report the incident
to the risk manager, who then informed the patient safety officer. Another effective strategy is to provide support and feedback to healthcare workers. This approach fosters teamwork and collaboration. When healthcare workers feel supported, they are more likely to report medication
errors, which helps identify areas for improvement and prevent future errors (Dilley & Kleiner, 1996).
IHI Triple Aim
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement (IHI) designed to optimize health system performance. The Triple Aim focuses on three primary goals: improving the individual’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of care (Mery et al., 2017).
Applying the Triple Aim to the medication error incident can help healthcare providers identify areas for improvement and prioritize patient safety. For example, reducing medication errors can enhance patient outcomes and improve the overall care experience. Additionally, it can lower the costs associated with treating the consequences of such errors.
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In my organizational improvement strategy, I will incorporate the Triple Aim's three goals: improving individual care experiences, enhancing population health, and reducing the per capita cost of care. By focusing on these elements, healthcare organizations can identify areas for improvement and emphasize patient safety. Improving patient outcomes and reducing costs contribute to creating a culture that values safety and quality of care.
Leadership & Collaboration Strategies
There are several evidence-based leadership and collaboration strategies to engage key organizational leaders in establishing a culture of safety and quality. One effective strategy is building relationships, which helps leaders build trust and promote collaboration. This can involve regular communication, sharing information, and involving leaders in quality improvement efforts. Providing education and training is another crucial strategy. By equipping key organizational leaders with knowledge on quality improvements and patient safety, they can better understand the importance of these initiatives and their role in fostering a culture of safety (Berry et al., 2020).
Key departments that should be directly involved in the corrective action process include nursing, risk management, and organizational leadership. Nurses are critical as they frequently administer medications and thus have a higher risk of encountering medication errors. The risk management department is essential as it manages various risks and errors, including medication errors. Organizational leaders must be involved because they are responsible for implementing corrective actions. Specifically, charge nurses, the chief nursing officer, the patient safety officer,
and the chief medical officer should be included in the action plan and held accountable for its implementation.
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Failing to engage all departments in prioritizing safety and quality can have significant implications. One major risk is an increased likelihood of errors and adverse events, which can harm patients and increase costs related to error consequences. Another implication is a lack of accountability, leading to a culture of blame and making it difficult to identify and address underlying issues contributing to errors.
To address the specific issue and cultural challenges, it is important to provide education and training on safety and quality to all departments. This ensures everyone understands the importance of safety and knows how to contribute to a culture of safety. Key leaders, such as the Chief Medical Officer, Chief Nursing Officer, Patient Safety Officer, and department leaders/supervisors, should play roles in modeling safe behaviors, establishing a culture of safety, providing necessary resources like education and training, monitoring progress, and involving staff.
To enlist their aid in improvement efforts, best practices include effective communication, providing feedback, offering education and training, and recognizing and rewarding success (Nash, n.d.).
Leadership Action Plan
Three strategies to address the medication error scenario in the Vila Health Patient Safety simulation include:
Developing a Medication Administration Review and Safety Committee: This committee will focus on reviewing medication administration processes and educating employees about safety protocols. By evaluating and discussing the safety of medication administration, the committee can identify areas for improvement and promote a culture of vigilance.
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Implementing a Double-Check Procedure: Establish a protocol requiring nurses to double-check each other’s work before administering medication. This ensures that two healthcare professionals verify the medication, reducing the risk of errors.
Reinforcing Education on Avoiding Medication Errors: Provide ongoing training to all healthcare workers on how to avoid medication errors and understand their risks. Educating staff on best practices and potential consequences will increase their awareness
and diligence in medication administration (Hodgkinson et al., 2006).
Three evidence-based best practices to address medication errors at an organizational level include:
Developing a Culture of Safety: Prioritize patient safety and quality improvement across the organization. Encouraging staff to report medication errors without fear of punishment fosters a culture where safety is paramount and continuous improvement is encouraged.
Implementing a Reporting System: Establish a robust system for reporting medication errors. This system should encourage staff to report incidents and help identify patterns and root causes of errors, facilitating timely interventions.
Conducting Regular Audits and Assessments: Perform regular audits and assessments of medication use processes. These evaluations help identify areas for improvement and ensure adherence to established medication safety practices (Cohen, 2007).
Opportunities to Enlist Governing Board
To enlist the governing board’s aid in fostering a fair and just culture, several strategies can be leveraged.
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1.
Establish Clear Expectations: The governing board should set and communicate clear expectations for a fair and just culture to the organization’s leadership and staff.
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Education and Training: Provide education and training to board members, leadership, and staff on the importance of a fair and just culture and how to foster it.
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Monitoring and Accountability: The governing board should regularly monitor the organization’s progress in fostering a fair and just culture and hold leadership accountable for achieving this goal.
By leveraging these opportunities, governing boards can play a critical role in fostering a fair and just culture in healthcare organizations. This culture is essential for promoting patient safety and quality of care, and the governing board has a responsibility to contribute to this goal.
The governing board’s role includes establishing the organization’s mission, vision, and values, fostering a culture of safety, and ensuring staff are encouraged to identify and report safety concerns. Overall, the board has a crucial role in ensuring that healthcare organizations provide safe, high-quality care to their patients. By fulfilling these roles, the board can help align the organization with its mission and goals and ensure the delivery of the best possible care.
To enlist the governing board’s support in improvement initiatives, the following steps should be
taken:
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Develop a Clear Plan: Outline a detailed plan for the improvement initiative.
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Communicate the Need for Improvement: Clearly communicate the necessity and benefits of the improvement.
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Demonstrate Potential Impact: Show how the initiative can positively impact patient outcomes.
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Seek Input and Support: Involve the board in discussions and seek their input and support.
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Provide Regular Updates: Keep the board informed about the progress and outcomes of the initiative.
Increasing the governing board’s involvement in the organization’s safety and quality improvement efforts is vital. Providing them with comprehensive information about these efforts
will enhance their understanding and engage them in discussions on performance improvement. Their support and engagement are key factors in achieving the goals of any improvement initiative.
Conclusion
In this analysis and leadership action plan for the medication error scenario in the Vila Health Patient Safety simulation, I outlined the scenario and proposed various strategies to address the issue and foster a culture of safety. Emphasizing the IHI Triple Aim helps healthcare organizations identify areas for improvement and prioritize patient safety. By striving to improve
patient outcomes and reduce costs, healthcare organizations can cultivate a culture that values safety and quality of care. Implementing the evidence-based strategies provided will ensure that medication safety practices are consistently demonstrated within the healthcare organization.
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References
Berry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2016). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system. Journal of Patient Safety
, 16
(2), 130–136. https://doi.org/10.1097/pts.0000000000000251
Cohen, M. R. (Michael R. (2007). Medication errors
(2nd ed.). American Pharmacists Association. Medication Errors - Google Books
Dilley, H., & Kleiner, B. H. (1996). Creating a culture of safety. Work Study
, 45
(3), 5–8. https://doi.org/10.1108/00438029610115451
Hodgkinson, B., Koch, S., Nay, R., & Nichols, K. (2006). Strategies to reduce medication errors with reference to older adults. International Journal of Evidence-based Healthcare
, 4
(1), 2–41. https://doi.org/10.1111/j.1479-6988.2006.00029.x
Impact of culture on health care
. (2003, August 1). PubMed. https://pubmed.ncbi.nlm.nih.gov/12934872/
Mery, G., Majumder, S., Brown, A., & Dobrow, M. J. (2017). What do we mean when we talk about the Triple Aim? A systematic review of evolving definitions and adaptations of the framework at the health system level. Health Policy
, 121
(6), 629–636. https://doi.org/10.1016/j.healthpol.2017.03.014
Nash S. B. R. M. S. J. D. B. (n.d.). The healthcare quality book : vision, strategy, and tools
. CiNii Books. http://ci.nii.ac.jp/ncid/BA80370172
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