Address a Patient Safety Issue

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Write a 23 page executive summary, examining a specific patient safety incident that took place and provide insights to senior leaders on the significance of addressing this issue.

Healthcare organizations have always searched for ways to identify and reduce risks. “Over the years, health care risk management has moved from a discipline focused almost exclusively on medical professional liability issues to a profession concerned with all of the risks associated with accidental losses facing a health care organization” (Carroll, 2009, p. 2).

Alarming numbers of unnecessary patient deaths occur in the U.S. hospitals and around the world. “Quality and patient safety in health care have been on the forefront of the public’s mind since the publication of the Institute of Medicine’s (IOM) seminal report, ‘To Err Is Human,’ in 1999” (Johnson et al., 2016, p. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive healthcare reform. Current approaches are not adequate; patients remain at risk for needless harm.

Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding healthcare quality, risk management, and patient safety overall.

References

Carroll, R. A. (2009). Risk management handbook for health care organizations. Jossey-Bass.

Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016). Case studies in patient safety. Jones & Bartlett Learning.

Step 1

Choose one of the three scenarios from the Vila Health: Patient Safety activity that interests you the most for further analysis in your assessment:

• Scenario 1: Patient Identification Error.
• Scenario 2: Medication Error.
• Scenario 3: HIPAA/Privacy Violation.

Executive Summary

Use the .

• Length: 23 double-spaced pages, excluding title and reference pages.
• Font and font size: Times New Roman, 12 point.
• APA format: Your submission, including the body, citations, and title and references pages, should conform to current APA format and style guidelines. Do make sure that it is clear, persuasive, organized, and well-written, without grammatical, punctuation, or spelling errors. You also must cite your sources according to current APA guidelines.

PowerPoint Presentation

Assume the role of a patient safety officer at your local hospital. Analyze a patient safety issue that occurred and then recommend to senior leaders about why it is important to address the issue, along with your recommendations about how to address it. Also provide details of the role you, as the patient safety officer, will play in helping the organization resolve the issue.

Be sure to include all of the following in your chosen format and to address all of the points:

• Apply the healthcare safety imperative to a patient safety issue.
• Identify the issue you selected from the Vila Health simulation as the potential safety threat.
• Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.
• Identify the implications of not addressing threat.
• Evaluate the risk to the patients, employees, and organization, if patient safety threats are not addressed.
• What does the healthcare safety imperative say about the issue?
• How does the healthcare safety imperative apply in this case?
• Which regulatory agencies have oversight about the issue?
• Analyze the patient safety officer’s role in implementing patient safety plans.
• Explain the role patient safety officers assume in implementing patient safety plans in healthcare organizations.
• Clarify your responsibility and role as the patient safety officer in this specific instance.
• Provide one example from the literature to illustrate your points.
• Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.
• Describe your five-point plan to reduce or eliminate this patient safety threat.
• What best practice tools or techniques does your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.

In a healthcare professional setting, recommendations to leadership would typically not be in APA format. However, your paper does need to conform to current APA format and style guidelines. It does need to be clear, persuasive, organized, and well-written, without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing. See the for more information about APA style.

Also, healthcare is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references do need to conform to current APA guidelines.

Please review the Address a Patient Safety Issue scoring guide to ensure you understand the grading requirements for this assessment.