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HCM 520 Colorado State University Healthcare Errors Discussion

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HCM520: Quality & Performance in Healthcare
HCM520: WEEK 8 Presentation & Discussion
Week 8 Portfolio Project: Quality and Risk PowerPoint Presentation
Quality and Risk Assessment Power Point Presentation
As healthcare leaders, it is important to combine your knowledge of management and quality to
understand and improve the organization (Spath, 2022). For your final Portfolio Project, you will do a
presentation that encompasses some of the key concepts covered in this course.
You will start by watching the following video: Chasing Zero: Winning the War on Healthcare Harm

Reference:
TMIT1. (2012, Aug 3). Chasing Zero: Winning the War on Healthcare Harm [Video]. YouTube.

Your goal is to address the areas of risk and quality improvement related to health/medical errors, as
well as to safeguard future patients from having their safety compromised like what occurred in the
video.
Instructions:
Your quality and risk assessment of the video must include:









Choose three (3) different medical error scenarios (or cases) discussed in the video
Discuss the 3 medical errors and root causes of errors. Be sure to include the following:
o Nature of error (error and root cause)
o Patient outcome
Identify the risk and discuss the risk management plans for each error scenario.
Determine the difference between system and process breakdowns that lead to medical
errors
Discuss statistical tools that could be used to improve safety
Discuss how the following could impact patient safety:
o Staff handoff
o Staff fatigue
o Staff incompetence
How does technology improve patient safety?
How does simulation improve quality?
What are your main take-a-way points from the video?
Submission Requirements:
Page 1
HCM520: Quality & Performance in Healthcare
Your Power Point Presentation should meet the following requirements:




Be 12-15 slides in length, not including the title or reference slides.
Be formatted for a formal presentation including headings per slide, major points per slide, and
presentation notes or embedded audio to supplement each slide provided as if you were doing the
actual presentation.
Cite at least eight scholarly references. Four of these references must be from outside sources, and four
may be from course readings, lectures, and textbooks. Include citations to support the statements made
and for each of the references listed on your reference slide(s).
Be submitted as a PowerPoint. Do not submit the presentation as a PDF file.
Week 8: Discussion Post ~ 300-500 words.
Reference: Taqiq, R.A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication dispensing errors and
prevention. National Library of Medicine.
Technology Systems and Medication Errors
It has been reported that 7,000 to 9,000 Americans die yearly as a result of medication errors (Tariq et
al., 2022). Additionally, hundreds of others experience other medication complications that went
unreported (Tariq et al., 2022). Over the years, technology has played a huge role in preventing
medication errors.
This week you will explore a technological system (i.e. COPE, barcode medication administration,
automatic dispensing) and discuss its impact on medication errors. You will first find an article that
focuses on a medication error where technology was implemented to improve the disbursement
process. Then, answer the following:





Provide background on the organization
Discuss the medication error and all the key players (Patient, Management, Employee, etc.)
How did this issue impact patient safety? What was the patient outcome?
What type of technology was used to improve patient safety?
Explain how the process has changed since the implementation of the technology.
References for PowerPoint / Discussion Post:
Page 2
HCM520: Quality & Performance in Healthcare
Agency for Healthcare Research and Quality. (2018). 10 patient safety tips for hospitals Links to an
external site.. https://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10tips/index.html
Agency for Healthcare Research and Quality. (2019, September 7). Handoffs and
signouts. https://psnet.ahrq.gov/primers/primer/9/handoffs-and-signouts
Agency for Healthcare Research and Quality. (2019, September 7). Never events.
https://psnet.ahrq.gov/primers/primer/3
Australasian College for Emergency Medicine. (2020). Clinical handover in the emergency department.
https://acem.org.au/getmedia/39955ff5-c492-448c-a740ea8c94ab4772/Guideline_on_Clinical_Handover_in_the_Emergency_Department
Bean, M. & Carbajal, E. (2022, March 1). ‘We can’t punish our way to safer medical practices’ : 2 experts
on criminalization of medical errors. Becker’s Hospital Review.
https://www.beckershospitalreview.com/patient-safety-outcomes/we-can-t-punish-our-way-tosafer-medical-practices-2-experts-on-criminalization-of-medical-errors.html
Canale, M. L. (2018). Implementation of a standardized handoff of anesthetized patients. AANA Journal,
86(2), 137–145
Casey, S., Avalos, G., & Dowling, M. (2018). Critical care nurses’ knowledge of alarm fatigue and practices
towards alarms: A multicentre study. Intensive & Critical Care Nursing, 48, 36–41.
https://doi.org/10.1016/j.iccn.2018.05.004
Joint Commission Center for Transforming Care. (2019). High reliability health care maturity model.
https://www.centerfortransforminghealthcare.org/high-reliability-in-health-care
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the
communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open,
8(8), e022202. https://doi.org/10.1136/bmjopen-2018-022202
Root cause analysis gone wrong. Links to an external site.(2019). AORN Journal, 110(4), 468–470.
https://doi.org/10.1002/aorn.12809
Spath, Patrice L. (2022). Applying quality management in healthcare: a systems approach (5th ed.). Health
Administration Press. **THIS IS OUR TEXTBOOK**
Theissen, A., Slim, K., Deleuze, A., & Beaussier, M. (2019). Risk management in outpatient surgery Journal
of Visceral Surgery,156(Supplement 1), S41–S49. https://doi.org/10.1016/j.jviscsurg.2019.04.005
The Leapfrog Group. (n.d.). When hospitals and surgery centers say “I’m sorry.”
http://www.leapfroggroup.org/influencing/never-events
U.S. Health Policy Gateway. (2017, June 23). Patient-Centered medical homes (PCMHs).
http://ushealthpolicygateway.com/vii-key-policy-issues-regulation-and-reform/patient-protectionand-affordable-care-act-ppaca/ppaca-research-and-analysis/
***Helpful Resources from this week’s readings for PowerPoint Presentation***:
Page 3
HCM520: Quality & Performance in Healthcare
Risk Management for Improved Patient Safety: The Changing
Environment
This last module, you will learn about the need for precise communication among healthcare providers
in various settings, including high-risk hospital departments. We will explore high-risk departments to
understand the impact on all of those involved when an error occurs. Additionally, once an error
occurs, how do we prevent it from happening again? The final topic in the module is root-cause
analysis, which can provide information to prevent future errors from occurring.
Learning Outcomes
1. Dissect root-cause analysis and discuss why this is approach can be considered proactive
improvement in healthcare settings.
2. Compare and contrast high-risk hospital departments.
3. Interpret risks in healthcare and recommend a risk management plan as a part of overall quality
improvement associated with a high-risk hospital setting.
4. Inspect staff handoff procedures and improvements that have an impact on patient safety.
1. Handoff Procedures in Healthcare
Poor communication among healthcare providers can cause serious patient safety issues. Concise, pertinent
communication is necessary to communicate important information. The Situation, Background, Assessment,
Recommendation Tool (SBAR) can be used to increase clear communication among healthcare providers. Do
you believe it is necessary to have a standardized approach for handoffs in healthcare? View more information
on SBAR
Another system for ensuring clear handoff communication is I-PASS. This is a mnemonic device/acronym that
stands for the following, as shown in this activity.
I = Illness severity (Agency for Healthcare Research and Quality, 2018a, para. 5)
P = Patient summary (Agency for Healthcare Research and Quality, 2018a, para. 5)
A = Action list (Agency for Healthcare Research and Quality, 2018a, para. 5)
S = Situation awareness and contingency planning (Agency for Healthcare Research and Quality, 2018a, para. 5)
S = Synthesis by the receiver (Agency for Healthcare Research and Quality, 2018a, para. 5)
The focus of I-PASS is to improve patient safety rates by using standardized forms of communication
amongst providers. The ultimate goal is to improve care transitions by reducing or eliminating
miscommunications that can happen as one provider hands over care duties to another.
Beyond I-PASS and SBAR, there are various tools used for patient handoff communication. Some of
these include: Smart Sign Out, Targeted Solutions Tool, and the Patient Handover Toolkit. A simple
internet search will yield many results on these specific tools, as well as multiple others.
Page 4
HCM520: Quality & Performance in Healthcare
It is vital to remember that within the healthcare environment, there are many areas where handoffs
occur. Handoffs do not only happen within the walls of a hospital. Areas and special situations to
consider include, but are not limited to:







Ambulatory centers,
Nursing homes/skilled care facilities,
Hospitals,
Handoffs involving residents,
Handoffs with language barriers,
Handoffs for testing, and
Nursing handoffs.
2. High-Risk Hospital Departments
When we speak of high-risk departments in the clinical area, does a specific department come to
mind? Perhaps you or someone you know has had to visit one of these departments.
There are four common high-risk departments that warrant special attention.




Emergency Medicine
Obstetrics and Neonatology
Surgery and Anesthesia
Intensive Care
These four areas within hospitals represent situations that carry the highest risk factors; these units
require specific standards, guidelines, and levels of service, as they have notable areas of concern. For
instance, Australasian College for Emergency Medicine (2020) reported that due to the high-risk of
clinical handover in the Emergency Department there is a need for a consistent and structured process
that support safe patient care. In response, they created a resource that support the implementation
of quality and safety improvements in clinical handover (Australasian College for Emergency Medicine,
2020). This process aims to mitigate risk, due to the highly complex and unpredictable nature of
emergency departments.
After being exposed to multiple examples of medical errors throughout the material in this course, did
any of these incidents, tragic situations, and the settlements related to these situations raise your
awareness regarding the potential problems we have in healthcare? It is quite evident, given the dollar
amounts of settlements, high-risk departments must be closely managed and assessed for
improvement. Our healthcare industry must strive to deliver the highest quality services at all times.
Surgery and Anesthesia
Let us explore one of the specialty areas referenced in the slides, surgery and anesthesia. Did you ever
consider that serious mistakes could be made in an operating room? Wrong-site surgery, medication
errors, burns, and retention of surgical sponges or instruments are just a few.
Never Event: Some generally accepted examples of a surgical never event are “surgery performed on the
wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging
an infant to the wrong person” (The Leapfrog Group, n.d., para. 2). These events are also considered sentinel
Page 5
HCM520: Quality & Performance in Healthcare
events by the Joint Commission and warrant a thorough investigation by risk management. They have been
reported to the Joint Commission since 1995.
Sentinel Events: Statistics show that the most common sentinel events are retention of a foreign body
(such as clamps or sponges), wrong-site/wrong-procedure surgeries, and falls (Becker’s Hospital
Review, 2017).
Bean and Carbajal (2022) report that the Joint Commission received 1,197 reports of sentinel events
last year and the most commonly reported safety event was patient falls, followed by delay in
treatment, and unintended retention of a foreign object.
In 2002, the initial never events list was designed; since then, the list has grown to 29 events
categorized into seven areas:







Surgical,
Product or service,
Patient protection [patient safety],
Care management,
Environmental,
Radiologic, and
Criminal (AHRQ, 2018b).
Review the following article regarding a wrong-site surgical case. After you review the article, do you feel this
mixture of problems was preventable? There are many other causes of preventable injuries in the surgical arena;
documentation of many such cases is easily accessible through internet searches.
https://www.magmutual.com/learning/article/case-study-wrong-site-surgery/
3. Root-Cause Analysis
Many healthcare entities aspire to be high-reliability organizations (HROs) Links to an external site..
Using Robust Process Improvement (RPI) tools is usually part of this process. According to the Joint
Commission Center for Transforming Care (2019):
Organizations concerned with quality and safety improvement will likely utilize root-cause analysis
(RCA) to understand and analyze why mistakes and medical errors occurred. The root cause of the
event is the most basic factor of why the event occurred, and, if removed, there will not be a repeat of
the incident. When discussing RCA, it is important to note that Spath (2022) stated, “An RCA focuses
primarily on systems and processes. Even though the mistakes of individuals often precipitated the
adverse event, the goal of the RCA is to find the problematic system or processes that set up people
to make these mistakes” (p. 261).
The Joint Commission
Page 6
HCM520: Quality & Performance in Healthcare
Based on its knowledge of health care and through studying the features of industries that have
achieved high reliability, The Joint Commission constructed a framework that health care
organizations can use to accelerate their progress toward the ultimate goal of zero harm. The
framework is organized around three major domains of change:
1. Leadership committed to the goal of zero harm.
2. An organizational safety culture where all staff can speak up about things that would negatively
impact the organization.
3. An empowered work force that employs RPI tools to address the improvement opportunities
they find and drive significant and lasting change (para. 2).
Page 7

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