Organizational Systems and Quality Leadership Task 2 Breanna Jordan Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis Although medical professionals take an oath to ‘do no harm’, errors in healthcare still occur. Patient safety is always priority when planning care for a patient; however adverse outcomes may take place resulting in a sentinel event. “A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
The ‘when’ is when will these risks harm this organization and ‘when’ will the countermeasures be applied to avoid these risks. The ‘why’ is the reason why these risks should be mitigated. There are many risks that are associated with any healthcare organization that can be prevented by implementing Information Security Strategies and critical IT components. One risk is the identity theft of the patient’s personal information such as social security numbers, credit card information, personal address, phone numbers, and insurance account information. Another risk could be a possible internal breach of security vulnerabilities such as cross-site scripting and SQL injections that could be exploited by either an unauthorized user or an employee via the internet or the intranet that could compromise the confidentiality of sensitive information.
There are many professional regulations and criminal liabilities defined in the health care industry. Acts and behaviors set as professional misconduct for physicians are placed for them to be aware of what situations may fall in these categories. The most common acts and behaviors reported as misconduct fit under groups such as negligence, incompetence, impairment, sexual abuse, and fraud (Jung, Lurie, & Wolfe, 2006). Medical misconduct is an issue faced by many physicians. This is an important aspect for physicians to understand because medical misconduct may prove to be detrimental to their career.
RUNNING HEAD: ANALYSIS OF SENTINEL EVENT 1 Analysis of Sentinel Event Western Governors University ANALYSIS OF SENTINEL EVENT 2 Unexpected adverse patient outcomes, such as death or severe physical or psychological injury, seldom occur due to a single causative factor within a healthcare organization. A root cause analysis (RCA) is a technique used to assist a healthcare organization in understanding the origin of adverse patient outcomes, and help develop processes that would prevent recurrence of adverse patient events. RCA focuses on the processes within the organization that contributed to the event, not a soul causative factor. A RCA looks to answer what happened to cause the event, what can be changed within the organization to prevent recurrence of the event, and evaluates if the changes that were implemented improved patient safety within the organization (Huber & Ogrinc, 2014). The complexity of a healthcare organization makes it difficult to conduct a RCA alone.
A failure mode and effects analysis will be used to project the likelihood that the process improvement plan suggested would not fail. I will also discuss the key role nurses would play in improving the quality of care in the situation of Mr. B. Root Cause Analysis According to Root Cause Analysis for Beginners, “root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of events with safety, health, environmental…impacts” (Rooney, 2004). The first step in doing a RCA is defining the problem. In the scenario of Mr. B’s sentinel event the problem is the untimely death of Mr. B, which could have turned out differently. The second step of a RCA is gathering information or the facts.
• How did it happen? “Sharp End” • Why did it happen? • What can be done to prevent it from happening again? “Blunt End” “Blunt End” Organizations, Policies, Culture Resources and Constraints Stress Forgetfulness Fatigue Distraction Haste Assumptions “Sharp End” Patient Acceptable RCA • Acceptable if: – Focuses on systems – not people – Progresses from special cause to common cause – Digs deeper asking why, why, why – Identifies changes through re-design or new system What’s thorough? • Thorough if: – Human and other factors associated with event identified – Detailed inquiry into the key areas specific to the event – Identification of contributing factors and root causes – Determination of improvements What’s Credible?
However it can be concluded from the Hippocratic Oath that the study of medicine has become more informal and mechanical in new age medicine. Due to this many professionals face moral and ethical dilemmas in the work place. Medical professionals who breach the code of ethics can be sued for medical malpractice lawsuits, lose their licenses and the trust of their patients. Medical malpractice is a patient or a patient’s family believing they were wronged by the healthcare system. This can be wrongful diagnosis, being given the wrong medication, or having their private information not properly protected.
The central line infections are one of the major complications of most surgical cases. Regardless of being a challenge to the hospital, it also threatens and challenges the patient’s life and health. Henderson et al., (2012) say that the hospital is exposed to losses and infections from the ICU. These accelerate and increase the budgeting of the hospitals and other medical institutions. However, institutions are now coming up with measures that they can apply in order to prevent the effects of the central line infections.
Researches in health care illustrated that service users continuously suffer from unnecessary preventable errors (Reader). In which interprofessional communication plays a significantly crucial role. The main purpose of communication was highlighted by one of the team member as the central way of progressing the service user’s (case study’s) care. The discussion was referred to the death of Victoria Climbie and the children undergoing heart surgery at Bristol. Improving management of care by effective and appropriate sharing information about duty spectrum of each particular profession for our individual service user was discussed within the team.
Since patients and families frequently ask nurses to provide information about support in dying, it is important for nurses to thoroughly understand the topic of physician assisted suicide regardless of whether it is legally permitted within the State where they are working (Ersek, 2004). The purpose of this paper is to describe benefits and disadvantages of assisted suicide and to discuss the ethical reasoning behind both of these opposing viewpoints. Review of Literature Throughout the literature, there are many arguments that support the prohibition of physician assisted suicide. One of the most obvious arguments is that health care providers are The Journal of Undergraduate Nursing Writing. 4:1.