Quality and Safety Paper
Arizona State University
Quality and Safety Paper
Nurses take great pride in patient safety because patients trust them and expect them to provide excellent and safe care. A patient that is safe leads to quicker recovery and release from the hospital. “Professional nurses are in a key position to identify and implement process improvements to enhance patient safety” (Good & Cash, 2016, p. 343). “The Joint Commission (TJC) sets standards for health care organizations and issues accreditation to institutions that meet those standards” (McMullen & Philipsen, 2016, p. 219). TJC sets National Patient Safety Goals (NPSG) yearly for health care organizations. NPSG.03.04.01 is a goal to more safely use medications (TJC, 2018, p. 2). Nurses can use the “SBAR method of structured communication” to better pass on anything medication related (Good & Cash, 2016, p. 350). “Just Culture” is about “creating an open, fair, and just culture” (Marx, personal communication, 2007, p. 18).
TJC and Specific NPSG
TJC developed NPSG’s in 2002 to help, “promote patient safety improvements based on recommendations made from sentinel event alerts, the Patient Safety Advisory Group, and review of current patient safety literature” (Good ; Cash, 2016, p. 343-344). NPSG.03.04.01 specifically looks at, “labeling all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings” (TJC, 2018, p. 2). When a patient is given or subjected to a wrong medication, this is considered an adverse drug event (ADE) (Patient Safety Network PSNet, 2018). PSNet states, “ADE’s are one of the most common preventable adverse events in all settings of care, mostly because of the widespread use of prescription and nonprescription medications” (PSNet, 2018). “Nearly 5% of hospitalized patients experience an ADE, making them one of the most common types of inpatient errors” (PSNet, 2018). According to TJC, “the labeling of all medications, medication containers, and other solutions is a risk-reduction activity consistent with safe medication management (TJC, 2018, p. 2). By taking the time to label medications and/or the containers medications are in, staff can more safely use and store the medication and keep the patients safe too.
Minimizing Risks through Communication Strategies
Communication is always key, but especially in minimizing medication errors and safety in using medications. Good and Cash state, “one of the primary trainable teamwork skills is communication, a foundational element to a healthy work environment and patient safety” (2016, p. 349). SBAR is a type of communication that bridges different communication styles and allows the information needed to be passed on correctly (Good & Cash, 2016, p. 350). SBAR stands for, “situation, background, assessment and recommendation” (Good & Cash, 2016, p. 350). This type of communication allows staff to outline the patient information that needs to be relayed each time (Good & Cash, 2016, p.350). Communication is one of the most essential pieces of safe medical care.
Just Culture is bringing awareness to learning from medical errors and changing the way those that make the errors are seen by their peers (Good & Cash, 2016, p. 346). “Just Culture is about defining safe systems and managing behavioral choices” (Marx, personal communication, 2007, p. 18). These two things are important factors in changing errors or near mistakes in medicine. Marx states, “making safe choices includes: following procedures, making choices that align with organizational values, and never signing for something that was not done” (personal communication, 2007, p. 22). Just Culture is bringing safety to the forefront and showing how not all who make mistakes need to be punished, some just need to be comforted during a rough time.
In conclusion, patient safety in all aspects of healthcare is a high priority and should never be taken lightly. TJC is an organization that helps set standards for healthcare facilities and allows the facilities to hold their accreditations (McMullen & Philipsen, 2016, p. 219). NPSG’s help promote safety guidelines, like NPSG 03.04.01 and safe medication labeling (TJC, 2018). SBAR communication can guide is safety of medication use and safety in communicating what is need for a patient, even when there may be a communication gap (Good & Cash, 2016, p. 350). Finally, Just Culture is defining ways to make sure safety is the standard and the errors are dealt with in the proper ways and not just causing people to be punished (Marx, personal communication, 2007).
Good, V. S., & Cash, K. R. (2016). Patient safety. In E. E. Friberg & J. L. Creasia (Eds.), Conceptual foundations: The bridge to professional nursing practice (6th ed., pp. 342?353). St. Louis, MO: Elsevier.
Marx, D. (2007). Patient safety and the “Just Culture” Slides. Retrieved from https://www.health.ny.gov/professionals/patients/patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf
McMullen, P.C., & Philipsen, N.C. (2016). Legal Aspects of Nursing Practice. In E. E Friberg & J. L. Creasia (Eds.), Conceptual foundations: The bridge to professional nursing practice (6th ed., pp. 207-222). St. Louis, MO: Elsevier.
Patient Safety Net (PSNet). (2018). Medication Errors and Adverse Drug Events. Retrieved from https://psnet.ahrq.gov/primers/primer/23/medication-errors
The Joint Commission (TJC). (2018). National patient safety goals effective January 2018: Hospital accreditation program. Retrieved from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2018.pdf