Hello,I need help with this assignment.Please strictly follow the rubric, and use the Sample Patient Safety Plan document as a guideline.The case study used for this assignment is CASE STUDY B!

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Hello,

I need help with this assignment.

Please strictly follow the rubric, and use the Sample Patient Safety Plan document as a guideline.

The case study used for this assignment is CASE STUDY B!

Hello,I need help with this assignment.Please strictly follow the rubric, and use the Sample Patient Safety Plan document as a guideline.The case study used for this assignment is CASE STUDY B!
IHP 315 Milestone Three Guidelines and Rubric You have developed your first three sections of your project and should be integrating feedback from your instructor to prepa re for the final submission in Module Seven. For this next step, you will develop your analysis of the patient safety culture of yo ur chosen case study and then propose communication and teamwork strategies to promote patient safety initiatives within your organization. In each of these sections, be sure to add ress the following elements: IV. Patient Safety Culture: In this section, you will analyze patient safety culture through the use of a survey as an assessment tool. Specifically, you should address the following: A. Analysis: Anal yze the patient safety culture survey results at the facility where the error occurred. In other words, what does this survey’s result tell you about the patient safety culture at the facility? Based on your analysis, what are areas for improvement? B. Outcome: In what ways might the outcome have been different if the facility had a stronger patient safety culture? Your response s hould be based on your analysis of the patient safety culture survey. C. Recommendation: Recommend one method that could be used to improve the patient safety culture. Justify your recommendation with your analysis of the survey. V. Communication: In this section, you will propose communication and teamwork strategies, explaining how these strategies promote safer patient care. Specifically, you should address the following: A. Strategy: What strategy or strategies could be used to improve communication and team building? Explain why you selected the strategy or strategies, basing your response on your analysis of the medical error and the patient safety culture. B. Safer Patient Care: How does the strategy (or strategies) promote safer patient care? What evidence do you have to support your response? C. Measurement: How will the communication and teamwork strategy or strategies be measured? In other words, how will we know that communication improved? To help with this milestone, see also the Sample Patient Safety Plan document . Specifically, take a look at the communication channels that exist within the organizati on to address safety events. Guidelines for Submission: Submit an APA -referenced and formatted paper that is 3 to 4 pages in length, excluding the cover page and reference list. This will be a Microsoft Word document with double spacing, 12 point Times Ne w Roman font, and one -inch margins. Rubric Critical Elements Proficient (100%) Needs Improvement (70%) Not Evident (0%) Value Patient Safety Culture: Analysis Analyzes the patient safety culture survey at the facility where the error occurred and identifies areas for improvement based on analysis with few gaps in the details Analyzes the patient safety culture survey at the facility where the error occurred and identifies areas for improvement, but analysis is cursory or inaccurate or areas for improvement are not based on analysis Does not analyze the patient safety culture survey at the facility where the error occurred and does not identify areas for improveme nt 15 Patient Safety Culture: Outcome Identifies ways the outcome might have been different if the facility had a stronger patient safety culture, primarily based on analysis of patient safety culture survey Identifies ways the outcome might have been different if the facility had a stronger patient safety culture, but response is not based on analysis of patient safety culture survey or has gaps in detail or logic Does not identify ways the outcome might have been different if the facility had a stronger patient safety culture 15 Patient Safety Culture: Recommendation Recommends method for improving patient safety culture, justifying recommendation with analysis of survey Recommends method for improving patient safety culture, but does not justify recommendation with analysis of survey or response has gaps in detail or logic Does not recommend method for improving patient safety culture 15 Communication: Strategy Proposes strategy or strategies that could be used to improve communication and team building, basing explanation on analysis of medical error and patient safety culture Proposes strategy or strategies that could be used to improve communication and team building, but explanation is not based on analysis or has gaps in detail or logic Does not propose strategy or strategies that could be used to improve communication and t eam building 15 Communication: Safer Patient Care Explains how strategy promotes safer patient care, supporting response with evidence Explains how strategy promotes safer patient care, but with significant gaps in detail, logic, or support Does not explain how strategy promotes safer patient care 15 Communication: Measurement Explains how the communication and teamwork strategy or strategies will be measured with minimal missing, unclear, or illogical details Explains how the communication and teamwork strategy or strategies will be measured, but with gaps in clarity, detail, or logic Does not explain how the communication and teamwork strategy or strategies will be measured 15 Articulation of Response Submission has no major errors related to citations, grammar, spelling, syntax, or organization Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 10 Total 100%
Hello,I need help with this assignment.Please strictly follow the rubric, and use the Sample Patient Safety Plan document as a guideline.The case study used for this assignment is CASE STUDY B!
IHP 315 Final Project Case Studies For your final project, select one of the following case studies to use as the basis for your error analysis and recommendations paper. Case Study A Karen Viani was newly diagnosed with congestive heart failure one month ago. Her primary physician prescribed a number of medications: a beta blocker to slow her heart rate, Lasix to treat the fluid overload, and digoxin for control of her symptoms. She also takes a potassium supplement. Ms. Viani is 76 years old, slim, and lives with her pet dog, Alfredo. She was hospitalized on Friday at noon at Mesa Valley Hospital, a 60-bed acute-care facility. This was after seeing her primary doctor for increased shortness of breath and after gaining four pounds in 24 hours. The hospitalist ordered a one-time dose of Lasix 20mg IV on admission followed by a lab order to check electrolytes in one hour. Recent hospital patient safety survey results identified some areas of strength and weakness. Strong positive responses were in the categories of organizational learning and continuous improvement at 78%; teamwork also scored a high 80% positive response. Areas with potential for improvement were staffing at a positive response rate of 25% and non-punitive environment and safety culture had a positive response rate of 20%. The nurse responsible for care of Ms. Viani was very busy. She gave the Lasix three hours after Mrs. Viani arrived and after the lab had drawn the blood for the electrolytes. When the hospitalist arrived at 1630, she noted the lab report indicated that the potassium level was low. The hospitalist assumed that the blood was drawn after Ms. Viani had received the Lasix. The hospitalist ordered another Lasix 20 mg IV. The evening nurse noted the order at 1700 and gave the potassium before dinner. During the evening mealtime, Ms. Viani suddenly felt light-headed, tried to reach the call bell that was on the bedside table, and fell on the floor. Ms. Viani sustained a small laceration on her forehead and a sprained right wrist, and then became quite disoriented and lost consciousness for a few seconds. The rapid response team (RRT) was notified and by the time the team arrived, Ms. Viani was lucid and was complaining of pain in her right wrist. The hospitalist ordered in the patient’s record that an incident report needed to be filed as the nurse made a medication error. The hospitalist has professional liability insurance as a condition of her employment at Mesa Valley. The nurse does not. Case Study B Twenty-year-old student, Paul, developed a right-sided pneumothorax while playing soccer at 1215. He had no prior remarkable medical history. His coach transported him to the Union Hospital Emergency Department at 1225, where he was triaged immediately due to his shortness of breath at 1250 and was seen by the emergency room doctor at 1300. Union Hospital is a 150-bed Level III trauma facility located in Cimarron View, a city of 25,000. The latest hospital safety survey indicated categories of strength (positive response) were supervisor promoting patient safety at 75% and management support for patient safety at 70%. Weak areas were staffing at a survey positive response of just 25% and a low 15% positive response for hand-offs and transitions. A chest film confirmed a right lower-lobe pneumothorax. The doctor ordered a thoracotomy insertion tray; as soon as the equipment was provided at the bedside, the nurse inserted the chest tube into Paul’s left side. As time was of the essence, no consent was signed and a time out, usually performed in surgery, was also not done. Following the chest tube insertion, there was no improvement in Paul’s shortness of breath. At this time, the nurse informed the physician that the chest tube had been inserted on the wrong side. Paul was becoming increasingly agitated and the physician mentioned to Paul what had happened. The nurse noted in Paul’s record that an incident report was filed for the wrong-side insertion, following the doctor’s written order to do so. The emergency physician attempted to have Paul admitted as an inpatient to Union Hospital so that the reinsertion could be done in the operating room. The time now was 1345. The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported and admitted to Jefferson Memorial, five minutes away. As an ambulance was on standby at Union, the emergency physician ordered immediate transport and also communicated with the surgeon at Jefferson about Paul’s condition. The unit secretary had just returned from taking a late lunch break and did not see the transfer order. The nurse was admitting another patient to the emergency department. The emergency physician, after writing Paul’s transfer orders, was now dealing with a serious motor vehicle injury patient. Paul oxygenation status continued to decompensate and he lost consciousness. At 1430, the secretary noticed the order and clarified with the nurse. When the nurse went to reassess Paul, he had expired. The physician has professional liability insurance as a condition of his employment at Union. The nurse does not.
Hello,I need help with this assignment.Please strictly follow the rubric, and use the Sample Patient Safety Plan document as a guideline.The case study used for this assignment is CASE STUDY B!
Page 9 of 9 IHP 315 Sample Patient Safety Plan PATIENT SAFETY PLAN PURPOSE This patient safety plan is designed to improve patient safety, reduce risk, and respect the dignity of those we serve by assuring a safe environment. Recognizing that effective medical/healthcare error reduction requires an integrated and coordinated approach, the following plan relates specifically to a systematic hospital-wide program to minimize physical injury, accidents, and undue psychological stress during hospitalization. The organization-wide safety program will include all activities contributing to the maintenance and improvement of patient safety. Leadership assumes a role in establishing a culture of safety that minimizes hazards and patient harm by focusing on the processes of care. The leaders of the organization are responsible for fostering an environment through their personal example; emphasizing patient safety as an organizational priority; providing education to medical and hospital staff regarding the commitment to reduction of medical errors; supporting proactive reduction in medical/healthcare errors; and integrating patient safety priorities into the new design and redesign of all relevant organization processes, functions, and services. MISSION The mission is to serve persons with exemplary quality care and compassion. VISION In the tradition of providing exemplary quality care, we serve as an instrument for good in a patient-focused, integrated healthcare system. Vision is evidence of intention and commitment. While mission describes our calling, what it is we are about, or how we participate in the healthcare ministry, our vision statement describes what we want to become. It contains our strategy to fulfill our mission. This is based on the following basic concepts: PATIENT-FOCUSED – Our mission is to provide compassionate care to patients, both those who come to us and those to whom we reach out. Decisions are based on what is good for the patient and are not self-serving. INTEGRATED HEALTHCARE SYSTEM – Services we provide address the continuum of life and are provided through common efforts, recognizing differing roles and responsibilities. Common decision criteria are employed throughout the system, with a common mission and vision. The vision is to focus on patient health outcomes with changes, improvements, and continuous monitoring of activities to ensure that the organization’s mission is consistently supported, assessed, reviewed, and revised as necessary over time. To carry on our mission and to follow through with our vision, it is necessary we work together as a team through the participation of members of the medical staff, governing body, employees, and leadership team in selected programs and functions. VALUES From the mission and vision flow the following values: Personal worth and dignity of every person we serve regardless of race, color, religion, and ability to pay Caring response to the physical, emotional, and spiritual needs of the people we serve Collaboration with each other, with physicians, and with other providers to deliver comprehensive, integrated, and quality healthcare Concern for physical, spiritual, emotional, and economical well-being of employees Quality work environments that focus on comprehensive, integrated quality service and opportunities for employee growth Open and honest communication to foster trusting relationships among ourselves and those we serve Responsible stewardship of the financial, human, and technological resources of the system Leadership in the health fields and in the communities we serve OBJECTIVES The objectives of the patient safety plan are to: Encourage organizational learning about medical/healthcare errors Incorporate recognition of patient safety as an integral job responsibility Provide education of patient safety into job-specific competencies Encourage recognition and reporting of medical/healthcare errors and risks to patient safety without judgment or placement of blame Involve patients in decisions about their healthcare and promote open communication about medical errors/consequences that occur Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions Report internally what has been found and the actions taken with a focus on processes and systems to reduce risk ORGANIZATION AND FUNCTIONS The patient safety team is a standing interdisciplinary group that manages the organization’s patient safety program through a systematic, coordinated, continuous approach. The team will meet monthly to assure the maintenance and improvement of patient safety in establishment of plans, processes, and mechanisms involved in the provision of the patient care. The scope of the patient safety team includes medical/healthcare errors involving the patient population of all ages, visitors, hospital/medical staff, students, and volunteers. Aggregate data* from internal (IS data collection, incident reports, questionnaires, ORYX reports, Core Measure reports) and external resources (Sentinel Event Alerts, evidence-based medicine, etc.) will be used for review and analysis in prioritization of improvement efforts, implementation of action steps, and follow-up monitoring for effectiveness. The severity categories of medical/healthcare errors include the following: No-Harm Error – an unintended act, either of omission or commission, or an act that does not achieve its intended outcome Mild to Moderate Adverse Outcome – any set of circumstances that do not achieve the desired outcome and result in an mild to moderate physical or psychological adverse patient outcome Hazardous Conditions – any set of circumstances, exclusive of disease or condition for which the patient is being treated, that significantly increases the likelihood of a serious adverse outcome Near Miss – any process variation that did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome Sentinel Event – an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes the loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome *The patient safety team will only evaluate aggregate data/processes and NOT specific clinical details related to individual occurrences. Clinical details will be reviewed/addressed through the established medical staff peer review process. The patient safety team will be chaired by the designated patient safety officer. The patient safety officer will be the director of quality resource management/risk manager. The responsibilities of the patient safety officer include compliance with patient safety standards and initiatives, evaluation of work performance as it relates to patient safety, reinforcement of the expectations of the patient safety plan, and acceptance of accountability for measurably improving safety and reducing errors. These duties may include listening to employee and patient concerns, interviewing staff to determine what is being done to safeguard against occurrences, and immediately responding to reports concerning workplace conditions. Team membership includes services involved in providing patient care (i.e., pharmacy, laboratory, surgical services, risk management, infection control, medical imaging, rehab, and nursing). The medical staff representative on the team will be the medical staff secretary. Discussion with the patient/family/caregivers regarding adverse outcomes: Events impacting the patient’s clinical condition – The patient safety officer will notify the caregiving physician about informing the patient/family/caregivers in a timely fashion (within 48–72 hours). Should the caregiving physician refuse or decline communication with the patient/family/caregivers, the department chairperson will be notified by the patient safety officer. The patient/family/caregivers will NOT be contacted without the permission and/or notification of the caregiving physician involved. The caregiving physician will determine the appropriateness of documentation of the occurrence in the medical record and will communicate this to the patient safety officer. Events NOT impacting the patient’s clinical condition, but causing a delay or inconvenience – The patient safety officer will communicate with the nursing manager the need for communication with the patient/family/caregiver in the interest of patient satisfaction. The mechanism to insure all components of the organization are integrated into the program is through a collaborative effort of multiple disciplines. This is accomplished by the following: Reporting of potential or actual occurrences through the Incident Occurrence Reporting Policy (Organizational Policy #6-004) by any employee in every department. Communication between the patient safety officer and the operational safety leader to assure a comprehensive knowledge of not only clinical, but also environmental factors involved in providing an overall safe environment. Reporting of patient safety and operational safety measurements/activity to the performance improvement oversight group, quality management council. The mechanism for identification and reporting a sentinel event/other medical error will be as indicated in Organizational Policies, Sentinel Event Policy, and Incident Occurrence Reporting Policy. Any root cause analysis of hospital processes conducted on either sentinel events or near misses will be submitted for review/recommendations to the patient safety team, quality management council, and the medical executive committee. As this organization supports the concept that errors occur due to a breakdown in systems and processes, staff involved in an event with an adverse outcome will be supported by: A non-punitive approach and without fear of reprisal, as evidenced by the amnesty policy. Voluntary participation into the root cause analysis for educational purposes and prevention of further occurrences. Resources such as pastoral care, social services, or EAP should the need exist to counsel the staff Annual staff surveys about their willingness to report medical errors F. As a member of an integrated healthcare system and in cooperation with system initiatives, the following patient safety measures will be the focus of patient safety activities: Adverse drug events Nosocomial infections Decubitus ulcers Blood reactions Slips and falls Restraint use Serious event reports DVT/PE Standardized defined measurements for each of the above is determined through the OSF Healthcare System Division of Strategic Effectiveness. Targets for improvement will be determined by the individual facility. This aggregate data will be reported to the patient safety team at monthly intervals. G. A proactive component of the program includes an annual selection of a high risk or error-prone process for concentrated activity, ongoing measurement, and periodic analysis. The selected process and approach to be taken will be communicated in a letter to quality council of the facility. The selection may be based on information published by TJC (The Joint Commission), Sentinel Event Alerts, and/or other sources of information including risk management, performance improvement, quality assurance, infection control, research, patient/family suggestions/expectations, or process outcomes. The process will be assessed to determine the steps where there is or may be undesirable variation (failure modes). Information from internal or external sources will be used to minimize risk to patients affected by the new or redesigned process. For each failure mode, possible effects on patients, as well as the seriousness of the effect, will be identified. The process will be redesigned to minimize the risk of failure modes. The redesigned process will be tested and implemented. Measures to determine effectiveness of the redesigned process will be identified and implemented. Strategies to maintain success over time will be identified. H. The procedures for immediate response to medical/healthcare error are as follows: 1. Staff will immediately report the event to the supervisor (either the nursing manager or the house supervisor if the event occurs during off-hours). 2. The supervisor will immediately communicate the event to the patient safety officer to initiate investigation and follow-up actions. Should this occur during off-hours, the administrator-on-call should be notified and a voicemail message left on the patient safety officer’s voicemail. 3. Staff will complete the incident/occurrence report to preserve information. 4. Staff will obtain required orders to support the patient’s clinical condition. 5. The operation safety leader will be notified of any situations of potential risk to others. The patient safety officer will follow usual protocols to investigate the error and coordinate the factual information/investigation for presentation, review, and action by the patient safety team and/or the sentinel event committee, as applicable. L. Methods to assure ongoing in-service education and training programs for maintenance and improvement of staff competence and support to an interdisciplinary approach to patient care is accomplished by: Providing information and reporting mechanisms to new staff in the orientation training Providing ongoing education, including reporting mechanisms Obtaining a confidential assessment of staff’s willingness to report medical errors at least annually Testing staff knowledge regarding patient safety in competency testing Evaluating staff knowledge levels and participation of patient safety principles in annual performance appraisals J. Internal reporting – To provide a comprehensive view of both the clinical and operational safety activity of the organization: The minutes/reports of the patient safety team, as well as minutes/reports from the operational safety committee will be submitted through the director of QRM to the quality management council. These monthly reports will include ongoing activities including data collection presented in statistical process control charts, analysis, actions taken, and monitoring for the effectiveness of actions. Following review by quality management council, the reports will be forwarded to the medical executive committee and to the OSF HealthCare System Board of Directors. K. External Reporting A high-risk or error-prone process will be selected annually for concentrated activity, ongoing measurement, and periodic analysis. The selected topic and approach will be communicated to the healthcare quality council through a written report. External reporting will be completed in accordance with all state, federal, and regulatory body rules, regulations, and requirements. O. The patient safety officer will submit an annual report to the board of directors and will include: Definition of the scope of occurrences including sentinel events, near misses, and serious occurrences. Detail of activities that demonstrate the patient safety program has a proactive component by identifying the high-risk process selected. Results of the high-risk or error-prone processes selected for ongoing measurement and analysis. (This will be communicated in the facility annual patient safety report due at the May board of directors meeting.) A description of how the function of process design that incorporates patient safety has been carried out using specific examples of process design or redesign that include patient safety principles. The results of how input is solicited and participation from patients and families in improving patient safety is obtained. The results of the program that assesses and improves staff willingness to report medical/healthcare errors. A description of the procedures used and examples of communication occurring with families about adverse events or unanticipated outcomes of care. A description of the examples of ongoing in-service and other education and training programs that are maintaining and improving staff competence and supporting an interdisciplinary approach to patient care. EVALUATION/APPROVAL The patient safety plan will be evaluated at least every three years or as changes occur, and revised as necessary at the direction of the quality management council. Annual evaluation of the plan’s effectiveness will be documented in a report to the medical executive committee, quality management council, chief executive officer, and, ultimately, the healthcare board of directors.

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