The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
Quality and Safety Issue
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission
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It has been developed over the years and is now known as Universal Protocol.
Impact on Health Care Delivery
Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.
In spite all the literature, documentation, and the lack of decrease in wrong site surgery, there are still providers who continue to rush and have the philosophy that time is money. Safety events and adverse events cost a lot of money (Laureate Education, 2010). Although adherence to universal protocol is required by Joint Commission since July 1, 2004, wrong site, wrong procedure, and wrong patient errors still occur. The incidence of wrong site surgery can be improved but needs to have the full participation of everyone involved in the process. Some of the reasons believed to add to the risk of wrong site surgery include poor planning, lack of
In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency
As noted by Haugen, Murugesh, Haaverstad, Eide, and Softeland (2013) wrong site surgery continues to be a problem that can be prevented through the use of a checklist. In 2008, WHO published guidelines to ensure the safety of surgical patients. The guidelines included
With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.
Wrong-site surgery is a serious and preventable occurrence, however, it continues to be a problem in
Causes of major medical errors have many different factors and influences. This includes why the patient was being seen to allow such an error, what medical guideline or guideline’s that where not followed that caused the error, what could have been done by staff members to prevent the error, etc. When errors take place, repercussions follow such as the cost incurred to the patient or patient family members, fines the medical worker must pay, and most importantly what is the patients status/prognosis. Not all patients prevail and make it through such awful medical errors.
In 2008, it was estimated that “medical errors total more than $19.5 billion” (Andel, 2012, p. 12). It is important to address and solve this problem at this time because the National Quality Forums (NQF) “never events” considers such events. Never events are events that occur that should have never occurred in the first place. Reducing and eventually eliminating wrong site surgeries will help improve patient safety in the operating room and become a leading example in improving patient safety in all aspects of healthcare.
Like others in New York, you may have, at one point or another, needed surgery to repair internal damage or treat a medical condition, among other reasons. When undergoing such procedures, you, and other patients, put your life and wellbeing in the hands of your medical provider. All too often, however, surgical errors occur that could be prevented.
1) According to the World Health Organization (WHO), how could at least half a million deaths due to surgical error be prevented every year?
The authors in this article discuss about how hospitals have been trying to cut back on costs while simultaneously attempting to provide high quality patient care. It is mentioned that approximately 200,000 Americans die yearly from preventable medical errors. It is up to the healthcare professionals to provide the best care possible for their patients.
One way you can help prevent surgical error is by choosing a surgeon and facility that is right for you. To do this:
Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)
Medicine is an always evolving field, and continues to grow in the pursuit of people health benefit. As time has passed better research studies, discoveries, treatments and improvement of patient outcomes has been the pride of the medical field. However; despite all the improvements in medical advancement, preventable medical errors have become a major problem in the field. About a decade ago, the Institute of Medicine (IOM) investigated and created the report To Err Is Human: Building a Safer Health System, in that report the IOM came to the conclusion that approximately 98,000 people has died yearly in the United States as a consequence of an preventable medical error (RWJF, 2011). Some of these errors are caused
According to the article Thousands of Mistakes Made in Surgery Every Year by Jennifer Warner from WebMD Health News, more than 4,000 mistakes occur in surgery every year that could have been prevented. These mistakes cost approximately $1.3 million dollars in medical malpractice payouts. This is a more than preventable act. Researchers frequently refer to these events as “never events” because they should simply never occur. Never events include incidents such as performing the wrong procedure or even leaving a medical sponge in the patient after surgery. Between the years of 1990 and 2010, never events occurred about 10,000 time in the United States. Each week a sponge or towel is left inside