Hospital National Patient Safety Goals, Essay Example

Introduction

One of the highest priorities of a healthcare organization must be to assure that their patients have a safe environment that is conducive to high quality health care. This philosophy is supported by the Institute of Medicine (IOM ) which declares that “patient safety is indistinguishable from the delivery of quality health care” (Mitchell, 2008). This philosophy extends to outlining safety protocols to prevent the risk of falls and injuries while in the hospital and to ensuring that patients are not subjected to unnecessary treatments and illnesses like ventilator associated pneumonia and catheter injuries. Thus, the purpose of this paper is to discuss patient safety in healthcare as it impacts healthcare professionals, organizations, and patients and their families. One of the aims of this paper is to address the fact that patient safety helps to lower healthcare costs and positively impacts policy changes and medical training. This paper also presents some recommendations for dealing with patient safety over the long-term.

Hospitals and related healthcare entities are not as safe as they should be for patients. According to the World Health Organization, one in ten patients are harmed when receiving care and treatment in a hospital setting (2014). Thus, many in the field of healthcare clearly understand that there is a great deal that needs to be done in order to improve the quality of patient healthcare. One current approach is the Hospital National Patient Safety Goals that focuses upon improving patient safety in hospitals. Some of these goals includes identifying patients correctly, improving staff communications, using medicines and alarms safely, preventing infections and surgical errors, and properly identifying patient safety risks (The Joint Commission, 2015).

The Importance of Patient Safety

Patient safety is not a new subject of debate, for as a major healthcare problem, patient safety has been discussed by medical professionals for many years. However, in the 1990’s, patient safety came of age when it became clear that many hospitals were not safe places to get well, due to the risks associated with patients harming themselves while under medical care. But today, patient safety is a globally recognized concern, especially related to a number of challenges that need to be overcome in order to implement hospital-based safety protocols and policies. As a matter of fact, hospitals deaths have become such as problem that the Joint Commission felt it was necessary to create National Patient Safety Goals in order to assist accrediting organizations with patient safety in specific areas. Other healthcare institutions have also initiated laws and guidelines that healthcare professionals are required to follow so as to help ensure patient safety.

As noted above, there are a number of challenges related to patient safety that need to be overcome. For example, it has been shown that staffing shortages tend to hinder the safety of patients, such as the inability to properly care for patients and the increased risks associated with  falls for elderly patients. According to Mitchell, the origin of many patient safety issues is related to the failures between patient or patient proxy and practitioners and non-medical staff, patient management, such as improper delegation, failures in tracking, wrong referrals, and the improper use of resources, and clinical performance before, during, and after an intervention (2008). Mitchell also notes that some of these failures are related to latency which involves decisions concerning the allocation of resources, procedures, and organizational policies. There are also failures linked to hospital administrations like the improper transfer of knowledge, wrong protocols and processes, organizational culture, and management (2008).

On the brighter side of the issue, the Department of Health and Human Services recently noted that 50,000 fewer patients have died in hospitals as a result of efforts to increase patient safety between 2010 to 2013. HHS also reported that more than $12 billion was saved related to making some much-needed changes in hospital conditions (Efforts to Improve Patient Safety, 2014). It should be mentioned that some of the changes associated with patient safety came about as a result of the passage of the Affordable Care Act which provides incentives for Medicare and Medicaid to improve the quality of care, along with the HHS Partnership for Patients. Although these facts signal an improvement in patient safety in hospitals, much more needs to be done, especially concerning the types of injuries which overall are totally avoidable.

Injuries and Illnesses Related to the Absence of Patient Safety

 One of the most common results related to the absence of patient safety are Hospital-Acquired Infections (HAIs). According to the Institute of Medicine, these types of infections have an estimated incidence of 4.5 per 100 hospital admissions and cost an estimated $35 billion to $45 billion on an annual basis (Glance, Stone, Mukamel, & Dick, 2011, pg. 794). HAIs thus account for close to 100,000 deaths per year and rank as one of the leading causes of death in the United States. HAIs range from foreign objects left in patients after surgery, air embolisms, incompatible blood during blood transfusion, and pressure ulcers. Also, accidental falls are responsible for electronic shock, burns, crushing injuries, intracranial injuries, dislocations, and fractures. There are also manifestations associated with poor glycemic control, such as secondary diabetes with hyperosmolarity and hypoglycemic coma, along with catheter-associated injuries like deep vein thrombosis. Of course, with the presence of patient safety protocols and directives, all of these type of illnesses and injuries are totally preventable.

Case Study

The case of Dorothea Handron is an excellent example on how patient safety is often compromised by lax regulations and protocols and incompetent surgeons. In June of 2014, Mrs. Handron was admitted to Vidant Hospital for a common hernia operation but ended up having her bowel pierced by the attending surgeon. Her infection was not discovered until five days later and when Mrs. Handron’s physicians decided to operate on her again, she was found to be so weak from an infection that had set in that she was placed in a medically induced coma. After her surgery, Mrs. Handron was placed on a respirator for six weeks while still in a comatose state (Rau, 2014). Thus, due to the medical complications experienced by Mrs. Handron, Vidant, an academic medical center in eastern North Carolina, “is likely to have its Medicare payments docked through the government’s toughest effort yet to crack down on infections and other patient injuries” that could be avoided by simply following and adopting patient safety procedures and protocols (Rau, 2014).

Along with the US federal government via the Department of Health and Human Services, the American Medical Association (AMA), and the National Patient Safety Foundation (NPSF), new ways of dealing with the lack of patient safety in many of America’s hospitals and health clinics have been devised with the goal being the “avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of care” (Emanuel, Berwick, Conway, Combes, et al., 2009, p. 6). Thus, in order to prevent incidents like that of Mrs. Handron, this “process of care” must be extended to all levels of a hospital environment which would include the ER, the OR, the ICU (intensive care unit), and the recovery areas where patient safety, like in other hospital areas, must be given top priority.

Improving Patient Safety

 In recent years, there has been a collective call to action by healthcare professionals throughout the healthcare industry to significantly reduce the number of injuries and illnesses associated with the lack of patient safety. According to the President and CEO of the American Hospital Association, an “infrastructure of improvement” related to patient safety has been created which will “aid hospitals and other healthcare organizations for years to come” and which has resulted in some significant improvements in 2015 (Efforts to Improve Patient Safety, 2014). A few of the areas affected by this new infrastructure includes improvements related to integration and coordination, decision making, engaging patients in the debate, and setting priorities related to patient wellness and injury/illness prevention.

One of the most important players in the move to increase patient safety in America’s hospitals and other healthcare institutions like clinics, nursing homes, and hospices, is Medicare. As noted in the Affordable Care Act, Medicare now has the power to hold hospitals accountable for injuries and illnesses associated with the lack of patient safety by penalizing them in relation to Medicare payments. This takes us back to the case of  Dorothea Handron in which the medical center had its Medicare payments docked as a response to Mrs. Handron’s infection which was totally avoidable. Currently, Medicare is most concerned with three areas related to penalties–1), the frequency of bloodstream infections in patients with catheters; 2), the rate of infections from catheters; and 3), the types of avoidable patient safety problems (Rau, 2014).

Recommendations

 First of all and perhaps most importantly, hospitals and other healthcare institutions must develop and implement patient safety initiatives and protocols that will monitor successes and failures and offer ways to prevent further patient safety concerns. Secondly, investments in technology must be made, especially in the areas of computerized physician orders and medications, and informatic systems that help nurses to keep track of patient treatments and healthcare needs. Thirdly, hospital staff members must be sufficiently trained in patient safety, much like employees in factories and manufacturing plants that must adhere to the regulations of OSHA.

In addition, hospital administrators must push for change management programs related to developing widespread support for patient safety and collaborate with community leaders to commit to patient safety programs. Overall, hospitals and other healthcare institutions must create and maintain a culture of safety which would include continuous training and on-the-job education. Also, hospital administrators and especially nurses must continue to search for new strategies that focus upon improving patient safety.

Conclusion

Without a doubt, patient safety is perhaps the most fundamental aspect of healthcare. After all, the first priority of a physician is to do no harm as declared in the Hippocratic Oath. Thus, patient safety is the foundation for keeping a patient free of harm. In basic terms, Emanuel, Berwick, Conway, Combes, et al. support the idea that all healthcare organizations must “adopt a definition and model for patient safety” which would be composed of four main domains–1), those who receive health care or the patients; 2), those who provide healthcare or physicians and nurses; 3), a system of therapeutic action; and 4), specific elements within each domain (2009, p. 16). In the end, by adopting this or a similar plan of action, patients will be guaranteed a new level of safety that will make their hospital stays more pleasant, encouraging, and of course, safer.

References

2015 Hospital national patient safety goals. (2015). Retrieved from http://www.jointcommission.org/assets/1/6/2015_HAP_NPSG_ER.pdf

Efforts to improve patient safety result in 1.3 million fewer patient harms. (2014). US Department of Health and Human Services. Retrieved from http://www.hhs.gov/ news/press/2014pres/12/20141202a.html

Emanuel, L., Berwick, D., Conway, J., Combes, J., et al. (2009). What exactly is patient safety? AHRQ. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf

Glance, L., Stone, P., Mukamel, D., and Dick, A. (2011). Increases in mortality, length of stay and cost associated with hospital-acquired infections in trauma patients. Archives of Surgery. Retrieved from http://www.cumc.columbia.edu/studies/pnice/documemts/            Increases%20in%20mortality,%20length%20of%20stay,%20and%20cost%20associated%20with%20hospital-acquired%20infections%20in%20trauma%20patients.pdf

Mitchell, P.H. (2008). Defining patient safety and quality care. In Hughes, R.G, ed. Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www/ncbi.nlm.gov/books/NBK2681

Rau, J. (2014). More than 750 hospitals face Medicare crackdown on patient injuries. Retrieved from http://kaiserhealthnews.org/news/patient-injuries-hospitals-medicare-hospital-acquired-condition-reduction-program

Rizzo, E. (2013). Top 10 patients safety issues for 2014. Becker’s Hospital Review. Retrieved from http://www.beckershospitalreview.com/quality/top-10-patient-safety-issues-for-2014.html

Wong, J., and Beglaryan, H. (2004). Strategies for hospitals to improve patient safety: A review of the research. Change Foundation. Retrieved from http://www.providence.on.ca/wp-content/uploads/2012/05/Change-Foundation-Improve-Patient-Safety.pdf