Submit a paper that identifies and examines two distinct types of sentinel events that frequently occur in healthcare organizations. The error types that you select must be significantly different; for example, patient suicide and wrong-site surgery.
In writing this paper, you should consider and address (as necessary) the following:
- Identify, compare, and contrast the system factors that influence organizational performance.
- Identify, compare, and contrast the processes and techniques that can be used to investigate, prevent, and control these types of events now and in the future.
- Identify, compare, and contrast the measures that can be used to assess the performance of the organization and the risk management plan in this area as it relates to patient safety.
Your paper should be well-written and meet the following requirements:
- Eight to 10 pages in length.
- Include at least six references from the peer-reviewed articles. The CSU-Global Library is a good place to find peer-reviewed articles.
- Conforms to CSU-Global Guide to Writing & APA.
Medical errors are unintentional acts which result from the use of incorrect plans to attain medical objectives or when planned actions fail to be accomplished as intended (David et al., 2013). Medical errors can take place at any stage in the process of providing care to patients, from diagnosis to treatment, and as well as provide preventive care. Some errors may result in harming patients while others may don’t. Those that result in harm are referred to as sentinel events. The sentinel events may harm patients psychologically, physically, or may even result in the death of patients. This paper, therefore, analyzes patient fall and delay in treatment as sentinel events by presenting the similarities and contrasts that surround them.
System Factors That Influence Organizational Performance
All patients regardless of their physical ability or age can be at the risk of falling due to physiological changes that arise from medication, medical conditions, procedures, or surgery that can leave them confused or weak. Various system factors contribute to patient fall which in turn influence organizational performance. The most common factors include inadequate assessment, poorly designed safety practices and protocols, lack of leadership, communication failures, and inadequacy of staff supervision, orientation, and staffing skill mix.
Delay in treatment is when patients fail to receive treatment, in the form of medication, laboratory test, or any other kind of treatment that had been ordered for them in the timeframe in which the patients were supposed to receive. The most common system factors that result in delay treatment include inadequate assessments, communication failures, the inadequacy of staff, poor planning, poor scheduling systems, and inadequacy of devices and equipment.
Patient fall and delay treatment have similarities and differences in the system factors which cause them. For instance, both events are caused by a communication failure. Effective clinical practices involve many situations where critical information has to be communicated accurately. When there is ineffective communication between healthcare professionals and patients as well as among healthcare professionals, the safety of patients becomes compromised (Vermeir et al., 2015). For instance, poor communication channels may hinder patients from asking for physical assistance and as result patients may fall and get injured when trying to assist themselves. Additionally, failure in communicating patient information to other staff during shift change increases the occurrence of falls. In regards to delay in treatment, communication failures include failure to timely report changes in patient condition, delay in reporting results, and giving incorrect information regarding patients.
Inadequate assessments is another common factor between patient fall and delay treatment. Inadequate assessment of patient care plans and clinical emergency response systems increase the likelihood of patient falls and delayed treatment. Besides, inadequate assessment of service delivery in the healthcare organization fails to pinpoint the gaps that may lead to both patient fall and delay treatment. When service delivery is poor, the sentinel events occur which in turn reduces patient turnover.
The inadequacy of staff is another factor which impacts the performance of healthcare organizations. When there is a wide disparity between the ratios of staff to patients, there exist delays in delivering of services which increase patient waiting time. This factor also increases the chances of patient fall as the weak become weaker during waiting. Besides, the delays lower patient satisfaction resulting in a patient turnover.
However, differences also exist between the system factors that result in patient fall and delay treatment. These factors influence the performance of healthcare organizations differently. The difference is that patient fall arises from poorly designed safety practices and protocols. Safety practices that lack prevention protocols to patients who have been screened and found to have high falling risks, lower the performance of the organization due to the increased litigations that result from a high rate of patient falls. Delayed treatment, on the other hand, mostly results from poor scheduling systems. When the supply timing of appointments does not match the supply of care providers, delays, especially in outpatients take place. As a result, patient satisfaction declines which in turn result in a patient turnover.
Investigation Processes and Techniques
Patient falls, and delay treatments are complex, multifaceted problems that require constant vigilance and continuous improvement of measures to sustain patient safety. Healthcare organizations thus need to have mechanisms for investigating sentinel events to determine the cause of actions and measures that need to be implemented to prevent future occurrences. The investigation process entails gaining approval to conduct the investigation, gathering information, determining the sequence of events, and determining the contributory factors. One of the techniques used to investigate the events is the use of interviews. Interviews can be conducted to staff, witnesses, and other parties that get involved in the event to collect details regarding the event. The use of root cause analysis is also another method for investigating patient fall and delay in treatment. The cause and effect approach can also be used to carry out investigations. With the cause and effect diagram, a comprehensive list of possible causes of the fall or delay in treatment is generated to assist in solving the problem. Besides, the technique allows identification of major causative factors as well as potential remedial actions. Moreover, the mechanism may indicate the potential areas that need further exploration and analysis.
The processes and techniques for investigating patient falls and delay in treatment display some similarities. For instance, in both events, the processes and techniques aim at finding the causative factors of the events. In particular, the use of root cause analysis to investigate both events focus on finding out what happened and why did the event happen. Furthermore, in both events, investigation techniques such as interviews focus on systems and processes and not on individual blames or performance.
The investigation mechanisms of patient fall and delay in treatment also portray differences. Investigations regarding patient fall normally focus in determining human interventions. The chances of patients falling highly depend on human factors such as communication and adequacy of staff. Delay in treatment investigations, on the other hand, focus on determining the sequence of events preceding the delay to find out the underlying factors.
Healthcare organizations employ a variety of mechanisms for preventing patient falls and delay in treatment. However, the success of these mechanisms depends on establishing and maintaining safe systems of care designed to reduce causative factors and improve human performance. There are various techniques used to prevent patient falls. One of the mechanism is to establish an interdisciplinary falls injury prevention team. With this technique, various organizational members including nurses, physicians, physical and occupational therapists, patient advocacy and other relevant stakeholders are included in the falls prevention team since it is the responsibility of every organization members to reduce falls.
Another technique is to use standardized, validated tools in identifying risk factors for patient falls. Besides, comprehensive, individualized assessments of falls risks have to be carried out. The assessments should include vital patient information such as age, cognitive status, and functioning level. Additionally, the staff should be trained to use the tools to ensure effectiveness.
Creating awareness of the need to prevent patient falls is another important preventive technique. Under this mechanism, communication of safety information conducted to both clinical and non-clinical staff at every level of the organization. Additionally, safety precautions have to be incorporated into the entire continuum of patient care and education via the use of change management tools such as staff empowerment (The Joint Commission, 2015). Furthermore, to support robust change management efforts, executive sponsors need to be empowered to ensure the facility has adequate resources and equipment, including staff and preventative devices such as alarms. Also, staff receptivity should be encouraged to patients requesting assistance.
Another approach to preventing patient falls is to develop individualized plans of care basing on recognized fall risks and to establish interventions basing on the specifications a patient or setting. Since all patients at the risk of fall, the care plan needs to identify risks that are specific to a patient and the actions for mitigating the risk.
Additionally, patient falls can be prevented through establishing standardize communication process for communicating the patient risk of fall between caregivers. For example, white boards could be used to communicate patient information and fall risks to staff during shifts or implementing a bedside shift report with information regarding falls risks (The Joint Commission, 2015).
The delay in treatment also has various preventative techniques. One of the techniques is to improve health information technology such as scheduling systems, electronic health records, and call back systems. Improved information technology helps to ensure that accurate and timely communication of patients’ information takes place (The Joint Commission, 2015). Besides, enhanced information technology support systems improve care by alerting patients to drug interactions and providing quick access to clinical guidelines.
Another strategy for preventing delays is developing a team culture. Healthcare structures are complex as they have competing responsibilities and an evolving perception of patient care as a collective role. It is thus beneficial to establish a culture of coordination of clinicians, services, and teams to work together in providing comprehensive care to patients. The technique promotes coordination and effective communication among all units thus mitigating factors that may result in a delay in treatment.
Ensuring the facility has sufficient infrastructure is another prevention technique for the delay in treatment. Excessive delays normally arise due to the inadequacy of devices and equipment. Therefore, the sufficiency of devices facilitates clinical procedures which in turn reduces the waiting duration of patients.
Additionally, in emergency departments, delay in treatment can be prevented by proper usage of existing resources. For example, the type and number of staff and the manner in which staff gets scheduled has to correspond to the timing and number of patients present in the emergency departments (Newfoundland Labrador, 2012). Additionally, supplies and equipment must be properly and conveniently stored to reduce the time spent to access them.
Furthermore, establishing community-based alternatives for emergency departments helps to mitigate treatment delays. Such alternatives include setting up urgent care clinics and developing after-hours primary care services. Community-based alternatives help in reducing the number of patient visits to emergency departments, thus preventing instances of delays in treatment.
There are similarities between the techniques and processes of preventing patient falls and delays in treatment. For instance, in both cases, effective communication is a key factor that needs consideration. In preventing patient falls, for example, there has to be effective communication between care providers and also between care providers and patients. In particular, during a change of shifts, information regarding the patient risk of fall has to be communicated to the caregiver taking the duty to help reduce the chances of fall of the patient. Similar to the approach of preventing delays in treatment, there needs to be effective communication between units as well as between clinicians. For example, coordination between units helps ensure timely communication of patient information and lab results thus reducing waiting durations of patients.
Another similarity is that when preventing both patients fall and delays in treatment, there exists the element of team work. In preventing patient falls, various stakeholders such as nurses and physicians have to work together to in reducing the falls. Similarly, in preventing delays in treatment, there needs to be coordination of clinicians, services, and units to facilitate the process of care giving in a manner that eliminates delays.
However, differences also exist between processes and techniques for preventing patient falls and delays in treatment. The main difference is that the techniques for preventing patient falls are a bit straight forward while those for preventing delays in treatment are somehow complex. For example, in preventing patient falls the organization can use simple approaches such as increasing number of staff and alarm devices. Prevention of delays in treatment, on the other hand, demands comprehensive approaches such as establishing community-based alternatives for emergency departments such as after-hours primary care services and the establishment of urgent care clinics.
Additionally, the techniques for preventing patient falls are less costly than those for preventing delays in treatment are. For example, in preventing delays in treatment, an organization has to invest in information technology such as electronic health records, and call back systems, as well as in emergency alternatives like the creation of urgent care units which are costly. Prevention of falls, on the other hand, uses less costly techniques such as encouragement of teamwork and effective communication.
Patient falls can result in morbidity, immobility, and mortality (Pasquetti, Apicella & Mangone, 2014). It is, therefore, necessary for healthcare organizations to implement sufficient control mechanisms for managing patient falls and associated injuries. One of the mechanism is to carry out continuous assessments and evaluations. The mechanism entails an evaluation of patient fall risks. Since patients’ risk levels of fall change anytime, hourly rounding can be conducted to ensure every patient receives the assistance they need such as moving from bed to bathroom or to the chair.
Another technique is to review the fall prevention techniques to identify gaps so that comprehensive measures can be established. For instance, prevention techniques should be modified depending on information obtained from studying patient falls. Additionally, mechanisms for measuring and reporting fall rates should be included in the prevention strategies.
Moreover, leadership support should be included in the prevention techniques. The frontline staff has to be involved in program designs and also multidisciplinary committee should assist in guiding the programs. The purpose of leadership is to ensure safety is made a top priority in the facility and that well-defined safety policies are formulated.
Additionally, regular education and training should be done on staff regarding quality improvement and skills required to reduce falls (Jackson, 2016). This approach enhances competence and skills of caregivers with regards to fall assessments.
It is also important to execute control techniques for delays in treatment. Monitoring of staff compliance with healthcare procedures is an important approach. While the delays in treatment care plan may consist potentially effective interventions, it is actually the compliance of staff that helps to reduce the delays. Therefore, it is necessary to monitoring staff compliance once the interventions have been developed.
Furthermore, carrying out evaluations, assessments, and reviews of processes and procedures that improve timeliness, completeness, and accuracy of communication is important in managing delays. Besides, reducing the reliance on verbal orders by requiring verification of information whenever verbal orders are also used helps to prevent misinformation that may lead to delays in treatment.
Similarities exist between the processes and procedures for controlling patient falls and delays in treatment. The main similarity is that evaluation, assessments, and reviews are employed in controlling falls and delays. The prevention mechanisms have to be constantly evaluated, assessed, and reviewed to rectify any loop holes that may compromise patient safety.
Also, in controlling both patients fall and delays in treatment, there is an element of leadership. For instance, in controlling falls, leadership support is used to ensure there are well-defined safety policies are implemented. Similarly, in controlling delays in treatment, leadership is also used to monitor staff compliance.
However, differences also exist. One of the difference is that the leadership element in controlling patient falls is used to ensure that well-defined safety policies are formulated during the establishment of safety programs. In controlling delays, on the other hand, leadership is used to ensure staff compliance with the implemented policies.
Also, the assessments conducted during the control of falls majorly focus on the condition of patients and the rate of falling in the facility. Contrary, assessments carried out in controlling delays in treatment focus on procedures and processes that improve timeliness, completeness, and accuracy of communication.
Measures for Assessing Performance and Risk Management
Fall rates have to be carried out and tracked as a tool for measuring quality improvement and fall risk management. By tracking fall rates, the organization is able to know whether there is an improvement in care or whether the situation worsens in response to the preventive practices. Furthermore, tracking fall rates help the organization to understand where it is coming from and whether improvement gains are sustainable (U.S Department of Health & Human Service, 2013).
Monitoring the frequency and duration of delay of events is a measure that helps in assessing the performance and risk management of a healthcare organization concerning delays in treatment. By tracking the duration and frequency of events delayed, the organization is able to determine if there is a significant improvement in care services. Besides, the approach helps to determine the likelihood of delays in treatment by analyzing the trend and duration of delayed events.
The measures involved in assessing performance and risk management in both patient fall and delays in treatment portray a similarity. In both cases, there is tracking of events over a particular period. For the case of patient falls, the rate of falls has to be monitored to determine if there are significant decreases in increases in falls. Similarly, in delays in treatment, the frequency and duration of delays have to be tracked to determine significant if patients receive care at the appropriate time.
However, the measures are distinct. In assessing performance and risk management concerning patient care, the focus is put on the number of patients. Monitoring is done on the portion of patients that fall in respect to the total number of patients in the facility. The performance and risk management in delays in treatment, on the contrary, focuses on monitoring the time taken during the delay of an event, and the how often events are delayed in the facility.
falls and delays in treatment are among
the most common sentinel events that occur in healthcare organizations. The
events have similarities as well as differences. In regards to the
similarities, the two events are caused by similar system factors that affect
organizational performance. Also, the events share some similar investigation,
prevention, and control processes and techniques. However, some causative
factors differ as well as investigation, prevention, and control techniques.
Furthermore, the measures for assessing performance and risk management plan
are similar in both events as they all consist of monitoring the performance
indicators. The difference, however, is that in patient falls, the focus is placed on monitoring the portion of
patients that fall in the facility while in a delay
in treatment, the focus is placed on
monitoring the time consumed during the delay
of events and the frequency at which delays take place.
David, G., Gunnarsson, C., Waters, H., Horblyuk, R. & Kaplan, H. (2013). Economic measurement of medical errors using a hospital claims database. Value in Health, 16, 305-310.
Jackson, K.M. (2016). Improving nursing home falls management program by enhancing standard of care with collaborative care multi-interventional protocol focused on fall prevention. Journal of nursing education and practice, 6(6), 84-96.
Newfoundland Labrador, (2012). A Strategy to Reduce Emergency Department Wait Times in Newfoundland and Labrador. 1-18
Pasquetti, P., Apicella, L. & Mangone, G. (2014). Pathogenesis and treatment of falls in elderly. Clinical cases in mineral and bone metabolism, 11(3), 222-225.
The Joint Commission, (2015). Preventing delays in treatment. Quick safety, 9, 1-2.
The Joint Commission, (2015). Preventing falls and fall-related injuries in health care facilities. Sentinel event alert, 55, 1-5.
U.S. Department of Health & Human Service, (2013). Preventing falls in hospitals. Agency for healthcare research and quality. Retrieved 09 September 2017 from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Vermeir, P., Vandijck, D., Degroote, S. & Peleman, R. (2015). Communication in healthcare: A narrative review of the literature and practical recommendations. International journal of clinical practice, 6(11), 1257-1267.