Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the
A. Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the following:
1. Describe a healthcare-related situation (S) prompting a systems-level patient safety concern that has the potential to impact multiple patients.
2. Analyze background (B) information about the concern by doing the following:
a. Describe the data that support or would support the need for change.
b. Explain how one or more national patient safety standards apply to this situation.
3. Assess (A) the impact of the safety concern on the patient(s), staff, and the organization as situated in the identified healthcare setting.
a. Explain how the safety concern affects value for the patient(s) and the healthcare setting.
4. Recommend (R) an evidence-based practice change that addresses the safety concern.
a. Discuss how this recommendation aligns with the principles of a high-reliability organization.
b. Describe two potential barriers to the recommended practice change.
c. Identify two potential interventions to minimize the barriers from part A4b to the recommended practice change.
d. Discuss the significance of shared decision-making among the healthcare setting’s relevant stakeholders in implementing this recommendation.
e. Describe an outcome measure that could be used to evaluate the results of the recommendation.
f. Describe the care delivery model currently being used in the healthcare setting.
i. Explain how the current care delivery model in the healthcare setting identified in part A4f would be impacted by the recommended change in part A4.
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
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Organizational Systems and HealthCare Transformation
D221
Mona Y. Shen
Western Governors University
Dr. Kallie Gatzemeier
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SITUATION: (Healthcare-related situations prompt a systems-level patient safety concern that
could impact multiple patients.)
1. Medication errors remain a major health problem in the healthcare system, medication
errors occur every 22.7 hours, and medication errors that adversely affect patient care
outcomes occurred 0.25% of all patients admitted in hospitals a year (Medication Error
in United States hospitals (2001) pubmed.ncbi.nlm.nih.gov/11560102/). In 2016 John
Hopkins released a longitudinal study between 2000 and 2008 of preventable deaths
caused by medication errors. The John Hopkins study calculated over eight years that
more than 250,000 deaths per year occurred due to medical errors making it a third
leading cause (hub.jhu.edu>2016/05/03>medical-errors-third). Medication errors are
preventable and are considered a never event. A never event according to National
Quality Forum (NQF), are errors in a healthcare setting that are identifiable, preventable,
measurable, and should not have happened in the first place.
BACKGROUND:
2a. (Describe the data support the need for change)
Medication errors cost the healthcare system an estimated 3.5 billion dollars annually due to
adverse drug events (ADE) and the estimated 3.5 billion dollars does not include the loss of
wages and productivity (Institute of Medicine, Committee on Identifying and Preventing
Medication Errors. National Academies Press; 2007:124-25).
The benefits of prevention of ADE promote to improve and facilitating zero patient harm, the
trustworthiness of the healthcare system to perform its due diligence in providing the best quality
care and outcomes for the patients, and the monetary savings can be utilized for improvements or
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upgrades in organizational healthcare technologies, software programming system, medical
durable equipment, streamline healthcare operations, additional resources, and support for staff
training, provide the community with health-related resources such as health education in
chronic disease management, or health prevention measures such as community gardening to
promote healthy nutrition lifestyles and provide low impact exercise activities such as Tai Chi.
2b. (Explain how one or more national patient safety standards apply to the situation)
Quality care and patient safety outcomes are the goals of every healthcare provider. However, the
detrimental impact of a never event occurring in a healthcare organization affects the perception
and places a negative stigma of the organization from the community if not corrected. HCAPS
(Hospital Consumer Assessment of Healthcare Providers and Systems) is the voice of the patient
and the patient’s family review and survey of the care they received at the healthcare facility. The
low HCAHPS score will negatively impact the organization’s reputation and limit the amount of
reimbursement from Medicare/Medicaid to the organization. Healthcare is also evolving from
fee-for-services (FFS) to value-based care payment. The FFS is a payment method based on the
quantity of care and not the value of care. Value-based healthcare is based on the quality of care
and the measuring of patient health outcomes. The center for Medicare/Medicaid service is
moving away from FFS to value-based care payment and private healthcare insurance is
following suit. Quality patient outcomes and financial benefits go hand in hand with the
organization’s success in the healthcare industry. It would be imperative for a healthcare
organization to facilitate medication error prevention, to do no harm, and to align with the
National Patient Safety Goals (NPSGs) under the Joint Commission. Who is the Joint
Commission (TJC)? The TJC is a United States-based nonprofit tax-exempt 501(c) organization
that accredits more than 22,000 US healthcare organizations and programs
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(https://en.wikipedia.org/wiki/Joint Commission). The mission and vision of TJC are to
continuously improve health care for the public, in collaboration with other stakeholders, by
evaluating healthcare organizations and facilitating the provision of safe and effective care of the
highest quality and value. TJC’s vision is that all people always experience the safest, highest
quality, best-value health care across all settings. TJC's main purpose is the assurance of
healthcare organizations meet the criteria to ensure policies and procedures are implemented to
safeguard patients’ safety. TJC annually inspects healthcare facilities and makes
recommendations if necessary. If the healthcare organization is not in compliance with the
patient's safety, the facility can incur penalties and monetary fines. The purpose of the NPSGs is
to assist and collaborate with the healthcare facility to improve patient safety, focusing on the
problem of healthcare safety issues, and how to correct and solve the problem.
ASSESS: (Assess the impact of the safety concern on the patients, staff, and the organization)
3a. We do not live in a perfect world void of human errors and mistakes. We must
acknowledge mistakes do happen and what we can learn from them, prevent them from
happening again, and not look to blame. When a medical staff unintentionally causes an error in
an ADE, there is a tendency to prompt our self-assessment and question our ability to provide
quality care, re-evaluating our judgment, skills, knowledge, and feelings of shame and guilt. One
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