an assessment of progress and emerging priorities in patient safety.

Reply 1

 

he safety of our patients is an important aspect of healthcare and is the basis of quality healthcare.  When patients come to the healthcare system there is an expectation of safety and quality healthcare however this is often not realized due to errors caused by healthcare workers. Reducing these errors will lead to improvements in quality of care and patient safety. According to Nickitas, Middaugh, and Aries (2016), the Institute of Medicine in a 1999 Seminal report stated that “To ERR is human” meaning that errors are inevitable because of the human aspect of healthcare.  The Institute of Medicine’s (IOM) seminal report in 1999, To Err, is Human: Building a Safer Health System became the basis of policy actions to improve patient safety.  The goal of this report was to design healthcare processes to ensure processes of care that will protect patients from accidental injury.  According to Rodziewicz, Houseman, and Hipskind (2021), approximately 400,000 hospitalized patients experience some type of preventable harm each year resulting in approximately 100,000 people dying each year and a c to hospitals of which costs approximately $20 billion per year. The IOM report (1999) gave rise to federal agency initiatives to improve patient safety in healthcare.  One such agency is the Agency for Healthcare Research and Quality (AHRQ). The AHRQ is a federal agency tasked with improving the safety and quality of America’s health care system by developing the knowledge, tools, and data needed to improve the health care system (AHRQ, 2021).  After the 1999 IOM report, AHRQ has been extremely effective in addressing patient safety.  According to AHRQ, the U.S. health care system prevented 1.3 million errors, saved 50,000 lives, and avoided $12 billion in wasteful spending from 2010–2013 (AHRQ, 2021).  Some of the more popular tools developed by AHRQ are the Team Strategies and Tools to Enhance Performance and Patient Safety 2.0 (TeamSTEPPS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), Guide to Patient and Family Engagement in Hospital Quality and Safety, Surveys on Patient Safety Culture (SOPS) (AHRQ, 2021).

2. The majority of health care errors occur in inpatient settings. Errors are becoming increasingly common in outpatient settings.  Discuss at least two (2) reasons for the increasing errors in outpatient settings.

Medical errors are a serious public health problem and a leading cause of death in the United States.  There are two main categories of errors; Errors of omission occur as a result of actions not taken and Errors of the commission occur as a result of the wrong action taken (Rodziewicz, Houseman, & Hipskind, 2021).  Medication errors are classified as errors of commission which are a big problem in the hospital setting as well as in ambulatory care.  In a 2011 study  by Sarkar et al., more than 4.5 million ambulatory care visits occur every year due to adverse drug events. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.  Risk factors for ADE include polypharmacy as well as health literacy.  In ambulatory settings, polypharmacy is a big problem and medication reconciliation by healthcare professionals is one way to reduce the dire effects of polypharmacy.  The level of health literacy of patients and their caregivers is a source of ambulatory care medical errors.  This leads to patients not taking the medication as prescribed which can lead to detrimental outcomes.  Another major error in ambulatory settings is missed diagnostics.  In a 2014 study, The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations, by  ​​Singh, Meyer, and Thomas, it is estimated that 5% of adults in the United States experience a missed or delayed diagnosis each year.  Missed diagnosis can delay treatments and reduce the likelihood of a good prognosis.

Reference

Rodziewicz, L., Houseman, B., and Hipskind, E. (2021).  Medical Error Reduction and Prevention. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Sarkar, U., López, A., Maselli, H., Gonzales, R.  (2011).  Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. https://pubmed.ncbi.nlm.nih.gov/21554271/

Singh, H., Meyer, N., Thomas, J.   (2014).  The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. https://pubmed.ncbi.nlm.nih.gov/24742777/

The Agency for Healthcare Research and Quality.  (2021).  Agency for Healthcare Research and Quality: A Profile. https://www.ahrq.gov/cpi/about/profile/index.html

The Agency for Healthcare Research and Quality.  (2019).  Ambulatory Care Safety.

https://psnet.ahrq.gov/primer/ambulatory-care-safety

Reply 2

 

Intentional fatalities in health-care settings are among the most tragic incidents that may occur to a patient seeking medical help. Unintentional deaths in health care settings, particularly those caused by medical mistakes, have been on the rise in recent years. To lessen the causes of unintended fatalities, such mistakes must be avoided. The importance of federal programs and patient safety in reducing medical mistakes in health care institutions is critical. Patient safety is a distinct health-care field that focuses on patient safety while receiving health-care services. Patient safety, moreover, is founded on the prevention, mitigation, reporting, and analysis of different medical mistakes that might result in negative consequences, including patient mortality (Liu et al., 2018). The World Health Organization now considers patient safety to be an endemic problem. As a result, patient safety plays a critical role in protecting the interests of patients by preventing many causes that might have negative consequences for them (Khan et al., 2018). Patient safety is a field that focuses not only on the safety of patients in a health-care setting, but also on actions that may be taken to ensure patient safety with minimum effort on the part of health-care personnel. As a result, patient safety plays a critical role in supporting the interests of patients by preventing a variety of circumstances that might have a negative influence on them (Khan et al.,2018). Patient safety is a field that focuses not only on the safety of patients in a health-care setting, but also on actions that may be taken to ensure patient safety with minimum effort on the part of health-care personnel. As a result, patient safety is critical in reducing medical mistakes in a health-care institution and preventing unintended fatalities among health-care workers.

2. The majority of health care errors occur in inpatient settings. Errors are becoming increasingly common in outpatient settings.  Discuss at least two (2) reasons for the increasing errors in outpatient settings.

Medical mistakes have now risen to become the industry’s third greatest cause of mortality, notably in the United States. Medical mistakes have exceeded other top causes of death, such as diabetes, Alzheimer’s disease, and strokes. However, the major issue in the health-care business is the causation of medical mistakes in outpatient settings. Medical mistakes in outpatient settings have been linked to an insufficient flow of information. There is little doubt that information flow is crucial in a health-care context, especially when different service areas are involved (Bates & Singh, 2018). However, there are times when there is an inadequate flow of information, particularly when important information is required, resulting in fatalities. Information such as the transfer of patients to other health-care institutions, for example, might result in medical blunders. Medical mistakes induced by a lack of information flow are mostly caused by a lack of communication of patient findings and a negative impact on pharmaceutical prescriptions. Medical mistakes have always occurred in such situations, resulting in serious health implications for the patients. Human personnel issues may contribute to medical mistakes in outpatient health care settings. More precisely, there have been several occasions when people’s carelessness has resulted in health care practitioners failing to guarantee that health care protocols, rules, procedures, and health care standards are followed appropriately in a health care environment. Poor labeling and record keeping can also describe the human issues in a health-care context (Royce et al., 2019). When health-care workers make mistakes owing to a lack of expertise, the consequences are frequently tragic.The health care providers must learn the importance of consulting with peers, appropriate application of expertise, and proper formulation of a health care plan. It is the role of a health care provider to consider the most evident disease diagnosis and practice of health care in such an automated sense to avoid medical errors in the health care settings, particularly in outpatient settings.

References:

Bates, D. W., & Singh, H. (2018). Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736-1743.

Liu, X., Zheng, J., Liu, K., Baggs, J. G., Liu, J., Wu, Y., & You, L. (2018). Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: A structural equation modeling analysis. International journal of nursing studies, 86, 82-89.

Royce, C. S., Hayes, M. M., & Schwartzstein, R. M. (2019). Teaching critical thinking: a case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Academic Medicine, 94(2), 187-194.