Question

Through a contemporary literature search, identify a significant patient harm event, and develop a proposal on how to address that scenario using a Just Culture solution. Include the following:

Brief introduction with synopsis of scenario and framing the proposal by describing analysis methods/models to be used and intended result (to provide improvement recommendations)

Just Culture assessment of the level of intent/risk of behaviors and your rationale

Provide specific performance management recommendations for the person(s) involved in the incident:

Console

Coach

Disciplinary Action

Human Factors assessment:

Identify human errors and the category of the errors: Knowledge-, Rule-, or Skill-Based

Identify Active and Latent Failure Factors contributing to errors identified

Provide relevant, logical root cause analysis (RCA) for identified factors

Provide specific improvement recommendations to address root cause(s) of failures

Use the human factors questions for analyzing systems as presented in Human Factors Analysis in Patient Safety Systems.

Use any other improvement models or methods reviewed in class (e.g. 7 Wastes, Value Stream, Flow, Standard Work, etc.)

Hint: You need to go beyond recommendations for training/communication

Consider potential barriers

Answer 1

A patient incident is any unplanned or unintended event or circumstances which could have resulted in harm to a patient. Different studies have been proposed to obtain adequate information about patient disabilities resulting from healthcare management specifically in adverse outcomes to patients in the course of health care management. Inaddition to this, 10-12% of patients experience hospital harm whilwe admission or transfering of patients and approxiamtely half of the events being considered preventable. RISKS OF BEHAVIOR IN PATIENT HARM; Health care delivery system must recognize the risk factors for errors and adverse events ensure a) effective communication with patients b) situation awareness c) high-reliability team to reduce the risks d) implement and empoly technology effectively and e) provide efffective ongoing education to trainees. HUMAN FACTORS ASSESSMENT IN PATIENT HARM: Patient safety is a global challenge that requires knowledge and skills in multiple areas and numerous conceptual methods and analysis are used in preventing and mitigating medical errors. The healthcare system emphasize the need for increasing partnerships between human factors and system engineering to improve patient safety. These partnerships will help them to design a system that are necessary to improve healthcare work systems and processes for patient safety.ROOT CAUSE ANALYSIS FOR PATIENT SAFETY HARM: Root cause analysis results in the identification and implementation of sustainable sytem based improvement to reduce the risks of harm in patients and to increase the patient safety. HUMAN ERRORS: Errors are defined as the act of commission that is doing something wrong or omission ( failing to do the right thing) leading to an undesirable outcome. Early detection may not experience patient harm to the incident and some adverse events can be preventable. IMPROVEMENT MODELS TO IMPROVE PATIENT SAFETY: The necessity for quality and safety improvement initiatives need healthcare to increase the awareness among patients. a) substantial and strong leadership supports to improve the quality improvement in making significant changes to the healthcare delivery system. b) ensure adequate financial suppport and identifying sources to train, purchase and testing new technologies and equipment c) active participation in the changing processes and d) emphasize safety as an organizational priority to improve the quality care and to reduce aptient harm.