Patient Safety and Risk Management Essay -- Health Care

Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis. Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root analysis is a systematic approach to collect information that may identify and evaluate hazards and risks (Williams, 2008). The root analysis provides a starting point on areas that may need changing. There are three areas to a root cause analysis of the adverse event which can enable the investigator to; 1) isolate the circumstances that increased the risk of an accident or incident from occurring; 2) determine who or what was involved in the situation; and (3) assess whether the facility might have control over the causes of the event (William, 2008). Using a report outline can help gather information consistency and completeness (Williams, 2008). The outline below evaluates the Samantha Jones adverse event. 1. Policy or Process (system) in Which the Event Occurred: a. The policy or process did not confirm the correct patient i. Nurses did not feel that they could voice their opinion about a proper time out b. Time out was not conducted thoroughly 2. Human Resources (factors and issues) a. No... ...004). Root cause analysis applied to the investigation of serious untoward incidents in mental health services Retrieved from. http://pb.rcpsych.org/content/28/3/75. Parker, D. (2008). Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF) Journal of Nursing Management; Mar2009, Vol. 17 Issue 2, p218-222. Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (2008). The healthcare quality book. (2nd ed.). Chicago, IL: Health Administration Press. Rooney, J.J. & Vanden Heuvel, L. N. (2004) Root Cause Analysis for Beginners. Retrieved from. https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdf Williams, L. (2008) The value of a root cause analysis. Long-Term Living: For the Continuing Care Professional, Nov2008, Vol. 57 Is