In the final phase of this project, you will implement your performance improvement plan. Also, you will discuss what the success of the performance improvement plan will look like. If you chose a problem in your workplace, be sure to use data from that healthcare organization. If you created a fictitious healthcare organization, you might use a public domain database with instructor permission. As you work on the final part of the assignment, include the following information in your paper.
Success of the Performance Improvement Plan
If this plan is successful, how would the organization monitor financial implications?
How would the current information management systems contribute to the success of your plan?
What current organizational processes will help the plan be successful?
How will the plan be communicated among departments? How will this communication help team members commit to the performance improvement plan?
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Mitigating Medical Errors in Health Systems
Courtney Roberts
July 9, 2023
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Mitigating Medical Errors in Health Systems
Identifying the Organizational Problem
Problem Description and Regulatory Implications
The healthcare organization under consideration faces a notable organizational challenge:
the elevated incidence of medical errors. Medical errors can encompass a range of situations,
including misdiagnoses, errors in medication administration, surgical mistakes, and other
treatment-related errors. These errors can potentially cause significant harm to patients, increase
healthcare expenses, and reduce the overall quality of patient care.
This issue violates the guidelines set forth by the ISO 9001 standard and regulatory
bodies such as The Joint Commission (TJC), which governs Quality Management Systems
(QMS). These guidelines require a constant enhancement in the quality of healthcare services to
optimize patient safety and satisfaction (Carver et al.,2023).
Organizational Challenges Posed by Medical Errors
Medical errors significantly impact various aspects of the organization, encompassing
interdepartmental conflicts, communication breakdowns, and budget management challenges.
Interdepartmental conflicts may arise due to divergent perceptions regarding responsibility and
misalignment in approaches to patient care. Communication breakdowns can arise due to
insufficient dissemination of crucial patient data or ineffective operational structures, thereby
giving rise to medical errors. From a financial perspective, medical errors have significant
implications, leading to escalated healthcare expenses due to malpractice litigation, extended
hospitalization periods, and the provision of redundant or unnecessary medical services
(Rodziewicz et al.,2023).
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Evidence-Based Support for the Problem
Despite the fictitious nature of our organization, empirical evidence from the real world
underscores the significant impact of medical errors. As per national data, it is estimated that
medical errors in U.S. hospitals alone lead to an annual mortality rate ranging from 210,000 to
440,000 deaths (Tariq et al.,2023). This places medical errors as the third leading cause of death,
following heart disease and cancer. The issue of medical errors has been previously tackled
through diverse strategies, such as using health information systems like Electronic Health
Records (EHRs) to guarantee patient data’s precision, availability, and promptness. Furthermore,
the utilization of Patient Safety Reporting Systems has been employed to effectively monitor and
analyze instances of errors and near misses, thereby providing valuable insights for
implementing specific interventions to enhance patient safety. Nevertheless, despite these
technological advancements, the persistence of medical errors indicates the necessity for a more
comprehensive and system-wide approach to address this issue (Singh et al.,2023).
Accreditation Standards and Safety Culture
Multiple accreditation standards and quality initiatives have been implemented to mitigate
medical errors and cultivate a culture of safety within healthcare organizations. The National
Patient Safety Goals (NPSGs) established by the TJC (The Joint Commission) specifically focus
on medical errors (Lark et al.,2018). The above standards encompass measures to enhance
patient identification accuracy, improve medication administration safety, and prevent
healthcare-associated infections. The purpose of these standards is to facilitate the adoption of a
proactive approach toward ensuring patient safety. Similarly, the Agency for Healthcare
Research and Quality (AHRQ) promotes cultivating a culture centered on safety by employing
its Hospital Survey on Patient Safety Culture. This initiative highlights the significance of
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ongoing education, collaborative efforts, and a patient-centric approach to mitigating medical
errors. Implementing these standards, along with the digitalization of health records and the
progress made in patient care technologies, fosters an environment that prioritizes safety, reduces
errors, and promotes the continuous enhancement of patient care quality (Karande et al.,2021).
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References
Carver, N., Gupta, V., & Hipskind, J. E. (2023). Medical Errors. In StatPearls. StatPearls
Publishing. http://www.ncbi.nlm.nih.gov/books/NBK430763/
Karande, S., Marraro, G., & Spada, C. (2021). Minimizing medical errors to improve patient
safety: An essential mission ahead. Journal of Postgraduate Medicine, 67(1), 1–3.
https://doi.org/10.4103/jpgm.JPGM_1376_20
Lark, M. E., Kirkpatrick, K., & Chung, K. C. (2018). Patient Safety Movement: History and
Future Directions. The Journal of Hand Surgery, 43(2), 174–178.
https://doi.org/10.1016/j.jhsa.2017.11.006
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical Error Reduction and
Prevention. In StatPearls. StatPearls Publishing.
http://www.ncbi.nlm.nih.gov/books/NBK499956/
Singh, G., Patel, R. H., & Boster, J. (2023). Root Cause Analysis and Medical Error Prevention.
In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK570638/
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2023). Medication Dispensing Errors and
Prevention. In StatPearls. StatPearls Publishing.
http://www.ncbi.nlm.nih.gov/books/NBK519065/
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Performance Improvement Initiative for Mitigating Medical Errors in a Healthcare
Organization
Courtney Roberts
July 23, 2023
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Performance Improvement Initiative for Mitigating Medical Errors in a Healthcare
Organization
The healthcare organization under consideration faces a critical challenge concerning the elevated
incidence of medical errors, encompassing misdiagnoses, medication administration mistakes,
surgical errors, and treatment-related issues. These errors not only jeopardize patient safety but
also lead to increased healthcare expenses and a decline in overall care quality.
To address this problem effectively, a comprehensive performance improvement plan is proposed.
The plan will adhere to the guidelines set forth by the ISO 9001 standard and regulatory bodies
such as The Joint Commission (TJC), which govern Quality Management Systems (QMS).
The performance improvement plan includes the following key components:
1. Root Cause Analysis and Process Standardization: The first step is to conduct a detailed
root cause analysis of reported medical errors. This analysis will help identify the
underlying factors contributing to the mistakes, enabling the organization to implement
targeted interventions. Processes and workflows for critical clinical tasks will be
standardized and continuously improved based on evidence-based practices to enhance
patient safety.
2. Training and Education: Regular training and education programs will be organized for
healthcare professionals to reinforce patient safety protocols, new procedures, and best
practices. These educational sessions will enhance the skills and knowledge of the staff,
ultimately reducing medical errors.
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3. Technology Implementation: Leveraging technology solutions, such as Electronic Health
Records (EHRs), clinical decision support systems, and barcode medication administration
systems, will be a central aspect of the improvement plan. These systems will improve
accuracy in patient care and minimize errors related to data management and medication
administration.
The performance improvement plan aligns with the quality standards set by The Joint Commission
(TJC) and focuses on reducing medical errors, enhancing patient safety, and promoting a culture
of continuous improvement.
To measure the success of the improvement plan, relevant data will be collected, including the
number of reported medical errors before and after implementation, rates of medication errors and
adverse drug events, patient satisfaction scores related to communication and care quality, staff
compliance with standardized processes and safety protocols, and time taken to complete critical
clinical tasks before and after process standardization.
Effective communication of the implementation plan among departments will be crucial. The plan
will be communicated through organizational meetings, presentations to key stakeholders, email
updates, dedicated training sessions for each department, and postings on the organization’s
intranet.
Data collected from various departments will be compiled into meaningful dashboards and reports,
which will be shared through regular data review meetings with department heads and staff,
display on notice boards in common areas, and distribution of comprehensive reports via the
organization’s communication channels.
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The successful implementation of the performance improvement plan is expected to have a
positive impact on patient care outcomes. The reduction in medical errors and adverse events will
lead to improved patient safety and a decrease in hospital-acquired complications. Patient
satisfaction scores are likely to increase as communication and care quality improve.
Health information systems, such as EHRs and clinical decision support systems, will support the
improvements in patient care by providing accurate and readily accessible patient data. These
systems will facilitate better clinical decision-making, medication management, and care
coordination, ultimately leading to enhanced patient outcomes.
Furthermore, the implementation of the plan is expected to foster a culture of safety within the
organization. Encouraging reporting of errors and near misses without fear of retribution will
create a learning environment. Staff engagement in safety initiatives, combined with continuous
quality improvement efforts, will instill a safety-first mindset, reducing the occurrence of medical
errors.
In conclusion, the proposed performance improvement plan aims to mitigate medical errors,
enhance patient safety, and improve the overall quality of care provided by the healthcare
organization. By standardizing processes, investing in technology, and prioritizing education and
training, the organization can make significant strides in achieving a culture of safety and
excellence in patient care.
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