Student Name
Capella University
BHA-FPX4004 Patient Safety and Quality Improvement in Health Care
Prof. Name:
Date
The purpose of this policy and procedure is to create a safe environment for both our patients and employees by:
Risk Elimination, Reduction, and Management: Identifying, reducing, and managing threats and vulnerabilities to patients, as well as to the hospital’s information systems and applications.
Optimizing Care Delivery: Maximizing opportunities for delivering optimal care while minimizing adverse events.
Enhancing Patient Safety: Identifying, resolving, and preventing potential risks throughout the hospital’s departments, with a central focus on patient safety and care.
Risk Prevention: Precautionary measures taken to eliminate foreseeable risks (Hofmann & Scordis, 2018). Example: Quarterly and annual reviews of Hospital Emergency Procedure manuals.
Risk Reduction: Decreasing the likelihood of risk occurrence (Hofmann & Scordis, 2018). Example: Mandating proper hand hygiene to reduce hospital-acquired infections.
Regulatory Compliance: Adherence to policies, laws, or recommendations for appropriate healthcare guidelines and operational practices (Dückers et al., 2009). Example: Complying with The Joint Commission’s patient safety procedure for proper patient identification.
Patient Safety: Initiatives and protections in healthcare aimed at preventing adverse harms to patients (Dückers et al., 2009). Example: Ensuring all bed rails are in the upright position to protect patients from falls.
Adverse Event: Incidents resulting in harm to a patient, hospital employee, or visitor. Example: A patient slipping and falling due to a wet spot on the floor (Dückers et al., 2009).
Near Miss: A prevented harm that could have resulted in unnecessary injury to a patient, employee, or visitor (Dückers et al., 2009). Example: A nurse noticing a discrepancy in patient information before administering medication.
Legal and Regulatory Compliance: Measures taken to adhere to healthcare policies and laws (Lee, Chang, & McCombs, 2019). Example: Compliance with the federal 340B Drug program.
Clinical and Patient Safety: Focus on patient safety initiatives and reducing patient fall rates (Nedved et al., 2012).
Technology Integrations: Implementing preventive measures to protect against cyberattacks (Ayatollahi & Shagerdi, 2017).
Infectious Disease Preparedness: Strategies to protect employees and patients from infectious diseases (Rebmann, Carrico, & English, 2007).
Employee Education: Annual training modules on risk management strategies.
Documentation: Complete and accurate documentation of all risk occurrences.
Departmental Preparedness: Promoting departmental cohesiveness on best practices.
Patient Concerns: Investigating and resolving patient concerns.
Participation in Surveys: Engaging in state, federal, or regulatory surveys (Ayatollahi & Shagerdi, 2017).
Cybersecurity: Protecting patient health information and hospital data (Ayatollahi & Shagerdi, 2017).
Health Information Management (HIM): Managing compliance and preventing coding vulnerabilities (Scott, 2015).
Billing and Collections: Ensuring error-free billing to avoid claim denials (Scott, 2015).
The Risk Manager is responsible for implementing programs and policies to identify, evaluate, and prevent risks throughout the hospital system (Seckel, 2013).
The potential risk being analyzed is Patient Identification Errors. These errors can disrupt patient care and lead to unnecessary harm (Clancy, 2005).
Strategies for identifying patient identification errors include conducting hospital-wide audits and providing education for frontline staff (Thomas & Evans, 2004).
To reduce patient identification errors, recommended changes include modifications to current processes, employee training, and IT safeguards (Cunningham, 2012).
Effective risk management policies can enhance patient safety and reduce errors (Benson, 2017).
Ayatollahi, H., & Shagerdi, G. (2017). Information Security Risk Assessment in Hospitals. Medical Informatics Journal, 11, 37–43. https://doi.org/10.2174/1874431101711010037
Benson, E. (2017). Mismatched How Patient Identification Errors Are Costing Patients And Health Systems. Health IT Outcomes. https://www.healthitoutcomes.com/doc/mismatched-how-patientidentification-errors-are-costing-patients-and-health-systems-0001
Clancy, C. M. (2005). AHRQ Quality and Safety Initiatives. The Joint Commission Journal on Quality and Patient Safety, 31(6), 354–356. https://doi.org/10.1016/s1553-7250(05)31047-6
Cunningham, B. (2012). Positive patient identification begins at step one. Health Management Technology, 33(8), 10-11. http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F1034737789%3Faccountid%3D27965
Hofmann, A., & Scordis, N. A. (2018). Challenges in Applying Risk Management Concepts in Practice: A Perspective. Risk Management and Insurance Review, 21(2), 309–333. https://doi.org/10.1111/rmir.12106
Lee, C., Chang, J., & McCombs, J. (2019). Specialty Drug Price Trends in the Federal 340B Drug Discount Program. Journal of Managed Care & Specialty Pharmacy, 25(2), 178–187. https://doi.org/10.18553/jmcp.2019.25.2.178
BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure Nedved, P., Chaudhry, R., Pilipczuk, D. & Shah, S. (2012). Impact of the Unit-Based Patient Safety Officer. JONA: The Journal of Nursing Administration, 42(9), 431–434. doi: 10.1097/NNA.0b013e318266810e.
Rebmann, T., Carrico, R., & English, J. F. (2007). Hospital infectious disease emergency preparedness: A survey of infection control professionals. American Journal of Infection Control, 35(1), 25–32. https://doi.org/10.1016/j.ajic.2006.07.002
Scott, P. (2015). Executive Perspectives on Top Risks for 2015. EDPACS, 51(6), 8–11. https://doi.org/10.1080/07366981.2015.1054250
Seckel, M. A. (2013). Maintaining urinary catheters. Nursing, 43(2), 63–65. https://doi.org/10.1097/01. nurse.0000425872.18314.db
BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure Thomas, P., & Evans, C. (2004). An Identity Crisis? Aspects of Patient Misidentification. Clinical Risk, 10(1), 18–22. https://doi.org/10.1258/135626204322756556
WHO. (2007). WHO: Identification Patient Safety Solutions. WHO Patient Safety Solution; Volume 1. https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf
Wilson, C. (2016). Patient ID Errors Happen—and they can be deadly. Health Exec; https://www.healthexec.com/topics/leadership/patient-id-errors-happen-and-they-can-be-deadly
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