Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis.
Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root analysis is a systematic approach to collect information that may identify and evaluate hazards and risks (Williams, 2008). The root analysis provides a starting point on areas that may need changing. There are three areas to a root cause analysis of the adverse event which can enable the investigator to; 1) isolate the circumstances that increased the risk of an accident or incident from occurring; 2) determine who or what was involved in the situation; and (3) assess whether the facility might have control over the causes of the event (William, 2008). Using a report outline can help gather information consistency and completeness (Williams, 2008). The outline below evaluates the Samantha Jones adverse event.
1. Policy or Process (system) in Which the Event Occurred:
a. The policy or process did not confirm the correct patient
i. Nurses did not feel that they could voice their opinion about a proper time out
b. Time out was not conducted thoroughly
2. Human Resources (factors and issues)
a. No translator or translation service in place
3. Environment of Care (including equipment and other related factors);
a. Did not have a way to elevate high risk patients
b. An electronic system such as a bar code is not in place
4. Information Management and Communication Issues
a. Improving communication among the staff
b. Management needs to empower nurses to speak when they feel there is a safety issue
The first step of the analysis is to collect data which will help with the understanding of the events. Identifying what data to collect and how and what to compare the results can be challenging. The organization should have a baseline to compare to see how the changes are working. Comparing information to similar organizations through benchmarking may indicate the success of the organization or program. Ransom, Joshi, Nash and Ransom (2008) state “benchmarking compares processes and success through gap analysis, process variation & organizational opportunities for improvement” (pg. 132). Data can be collected from prior litigations and claims information. Monitoring the information through monthly reports can indicate if process modifications or changes are needed. Once information is identified...