DNP 835 Topic 1 DQ 1 PS 101: Introduction to Patient Safety Reflection Example

Assignment Brief: DNP 835 Topic 1 DQ 1 PS 101: Introduction to Patient Safety Reflection Assignment

Assignment Overview:

In this assignment, you will engage in a reflective analysis of the discussions in DNP 835 Topic 1, specifically focusing on Patient Safety (PS) 101: Introduction to Patient Safety. The objective is to critically evaluate and respond to key concepts and insights shared by peers in the context of patient safety practices and initiatives.

Assignment Objectives:

• Reflect on Patient Safety Discussions: Your main task is to think about the discussions that happened in DNP 835 Topic 1, particularly those related to patient safety. Consider various perspectives, insights, and experiences shared by your peers and evaluate their implications for healthcare practices.
• Incorporate Assigned Readings: Include relevant information from the assigned readings, including references to the Joint Commission’s key elements, Lawati et al.’s systematic review, and the study by Storesund et al. on the impact of checklists in surgery.
• Analyze Leadership Commitment: Evaluate the commitment of healthcare leadership to patient safety, as discussed in the posts. Assess the outlined strategies and principles for fostering a culture of safety within healthcare organizations.
• Explore Surgical Safety Checklists: Look into the effectiveness of surgical safety checklists, drawing insights from the discussions on the World Health Organization Surgical Safety Checklist and the Surgical Patient Safety System (SURPASS) checklists. Consider how these tools contribute to preventing complications and improving patient outcomes.
• Evaluate Nursing Errors: Think about the challenges and factors contributing to nursing errors, as highlighted in the posts. Analyze the implications of these errors for patient safety and explore potential strategies to address them.
• Apply Patient Safety Concepts: Consider real-life examples shared by peers, such as the case of a doctor administering the wrong blood due to onboarding processes. Discuss how the principles of patient safety can be applied to mitigate such errors and improve overall healthcare processes.

The Student’s Role:

As a student, your role is to actively engage with the content discussed in DNP 835 Topic 1. Participate in the reflective process, bringing in your insights and experiences related to patient safety. Demonstrate a comprehensive understanding of the assigned readings and apply the concepts to the context of patient safety in healthcare settings. Your reflections should go beyond summarization and aim to provide thoughtful analyses, considering the broader implications for healthcare delivery and patient outcomes.

Detailed Assessment Instructions for the DNP 835 Topic 1 DQ 1 PS 101: Introduction to Patient Safety Reflection Assignment

DNP 835 Topic 1 DQ 1 Reflecting on the “IHI Module PS 101: Introduction to Patient Safety,” summarize why it is essential to improve patient safety

Topic 1 DQ 1

Reflecting on the “IHI Module PS 101: Introduction to Patient Safety,” summarize why it is essential to improve patient safety. Use one of the articles from this week’s topic Resources and describe the framework or theory that was used to improve the patient outcome. What outcome measures were identified and how did they align with the improvement project? Explain how the authors learned from the error or unintended events to ensure patient safety. Provide supporting evidence.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.

Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.

One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.

I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.

In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.

Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).

Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).

Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.

I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.

As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.

It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

DNP 835 Topic 1 DQ 1 PS 101: Introduction to Patient Safety Reflection Example

Reflection on IHI Module PS 101: Introduction to Patient Safety:

Improving patient safety is a critical aspect of healthcare, and the IHI Module PS 101 sheds light on the key elements, including leadership, policies, transparency, validation, and just culture, necessary for fostering a safety culture. The relevance of patient safety is emphasized through its impact on the quality of care. Safety culture, as defined by Lee et al. (2019), is shaped by individual and group values, attitudes, perceptions, competencies, and behavior patterns, determining an organization’s commitment to health and safety management.

Nurses, as frontline healthcare workers, play a pivotal role in promoting patient safety. Nursing knowledge, derived from nursing theories, is a valuable asset for delivering patient-centered care and improving outcomes (Ortiz, 2021). The importance of proper assessment and adherence to guidelines is highlighted by Haley and Fritz (2019), emphasizing the need to treat the resident and not the urine in long-term care settings.

Leadership commitment to a safety culture is crucial, as highlighted in the Joint Commission’s key elements. This commitment involves communication of support, modeling expected behavior, creating a code of conduct, fostering an environment for reporting errors without fear of punishment, and promoting collaboration across disciplines (Joint Commission, 2019).

The focus on patient safety extends to perioperative care, where the use of checklists, such as the World Health Organization surgical safety checklist and the Surgical Patient Safety System checklists, has a significant impact. The study by Storesund et al. (2020) demonstrates the effectiveness of these checklists in reducing adverse events, unplanned repeat surgeries, and rehospitalization rates.

The implementation of the World Health Organization Surgical Safety Checklist globally resulted in a noteworthy reduction in complications and mortality rates (Haugen et al., 2019). The emphasis on protocol adherence and the checklist’s comprehensive nature contribute to improved patient safety outcomes.

Patient safety is not without challenges, and errors, particularly in nursing, are prevalent. Factors contributing to nursing errors include heavy workload, inadequate knowledge, and suboptimal working environments (Mohsenpour et al., 2017). It is crucial to address these challenges systematically and collaboratively to enhance patient safety.

Reflecting on personal experiences, the need for effective onboarding processes and systematic approaches to addressing errors is evident. Ordering unnecessary labs, as discussed by Haley and Fritz (2019), highlights the importance of empowering nurses with clinical judgment skills to avoid overuse of medical resources.

References:

Haley, T., & Fritz, S. (2019). Treat the resident, not the urine: Using patient safety to reduce urinary tract infections and overuse of urine culture in long term care. American Journal of Infection Control, 47(6), S8. https://doi.org/10.1016/j.ajic.2019.04.148

Institute for Healthcare Improvement. (n.d.). Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement. https://my.ihi.org/

Joint Commission. Comprehensive accreditation manual for hospitals (CAMH). Oakbrook Terrace (IL): Joint Commission Resources; 2019.

Lee, S. E., Scott, L. D., Dahinten, V. S., Vincent, C., Lopez, K. D., & Park, C. G. (2019). Safety culture, patient safety, and quality of care outcomes: a literature review. Western journal of nursing research, 41(2), 279-304.

Mohsenpour M, Hosseini M, Abbaszadeh A, et al. Iranian paediatric nurses experience of nursing error: a content analysis. HK J Paediatr (New Series) 2017; 22: 97–102.

Ortiz, M. R. (2021). Best practices in patient-centered care: Nursing theory reflections. Nursing Science Quarterly, 34(3). https://doi-org/10.1177/08943184211010432

Storesund, A., Haugen, A. S., Flaatten, H., Nortvedt, M. W., Eide, G. E., Boermeester, M. A., Sevdalis, N., Tveiten, Ø., Mahesparan, R., Hjallen, B. M., Fevang, J. M., Størksen, C. H., Thornhill, H. F., Sjøen, G. H., Kolseth, S. M., Haaverstad, R., Sandli, O. K., & Søfteland, E. (2020). Clinical efficacy of Combined Surgical Patient Safety System and the World Health Organization’s checklists in surgery. JAMA Surgery, 155(7), 562. https://doi.org/10.1001/jamasurg.2020.0989

Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019). Impact of the world health organization surgical safety checklist on patient safety. Anesthesiology, 131(2), 420-425.

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Thank you for your insightful post. I concur with your statements regarding the critical importance of prioritizing patient safety. Particularly noteworthy is the assertion, “Due to the complexity of the healthcare system about patient care, practicing patient safety is vital to preventing errors and harm when caring for the patient. Nurses contribute to and promote patient safety practices.” In alignment with the Joint Commission’s key elements, the leadership of my organization has dedicated itself to fostering a safety culture. This commitment involves holding themselves and others accountable for the following:

• Communicating leadership support for a culture of safety.
• Modeling expected behavior within a safety culture.
• Developing and enforcing a code of conduct that defines appropriate behavior supporting a safety culture and unacceptable behavior that can undermine it.
• Creating an environment where people can speak up about errors without fear of punishment; utilizing this information to identify system flaws contributing to mistakes.
• Applying a fair and consistent approach to evaluate the actions of staff involved in patient safety incidents.
• Supporting event reporting of near misses, unsafe conditions, and adverse events.
• Identifying and addressing organizational barriers to event reporting.
• Cultivating an organization-wide willingness to examine system weaknesses and using findings to improve care delivery.
• Promoting collaboration across ranks and disciplines to seek solutions to identified safety problems.
• Periodically assessing an organization’s safety culture to track changes and improvements.

(Joint Commission, 2019)

Jan 9, 2023, 6:30 PM

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Patient safety is the practice of preventing mistakes in medical care. It is essential to the quality of treatment that patients receive because even minor errors can negatively affect their general well-being. Patient safety requires a dedication to ongoing development and an emphasis on reducing risks and averting potential harm (Lawati et al., 2018). Patient safety is crucial because it protects patients from injury and raises the standard of care in general. Patients are more likely to experience better health outcomes when they receive safe care. As a result, it is crucial for healthcare professionals to put patient safety first and strive tirelessly to increase the security of the treatment they deliver. This essay describes the use of checklists in the perioperative care pathway to improve surgery patients’ safety and outcomes.

According to Storesund et al. (2020), the study aimed to determine the impact of the World Health Organization surgical safety checklist (WHO SSC) and the Surgical Patient Safety System (SURPASS) checklists on patient treatment results such as illness, death, and hospitalization length. The research design involved introducing the pre- and post-operative SURPASS checklists to the intraoperative surgical safety checklist in surgery departments at a tertiary hospital in Norway using a nonrandomized clinical trial approach. The primary purpose of these checklists was to improve patient outcomes by consistently following key safety steps throughout the perioperative care pathway.

My focus is to assess the incidence of complications during hospitalization, unplanned repeat surgeries, unplanned return visits within thirty days of being discharged, and death within thirty days. These outcomes were chosen because they are all indicators of patient safety and have the potential to have a significant impact on patient outcomes. The study aimed to improve patient outcomes overall by lowering the occurrence of complications, reoperations, and readmissions, as well as improving survival rates.

This study used the length of hospital stay (LOS) as a secondary outcome measure. While LOS is not directly related to patient safety, it can be an important indicator of the perioperative care pathway’s efficiency and effectiveness. The study aimed to improve the overall efficiency of the perioperative care pathway by lowering the LOS, which could lead to cost savings and improved patient satisfaction (Storesund et al., 2020). The identified outcome measures were generally aligned with the improvement project, as they were chosen to assess the impact of the checklists on key indicators of patient safety and efficiency in the perioperative care pathway.

The joint application of the two checklists was linked to decreased adverse events while in the hospital, unplanned repeat surgeries, and rehospitalization rates. According to Storesund et al. (2020), this finding raises the possibility that using these checklists could help identify and prevent mistakes or unintended events in the perioperative care pathway, improving patient outcomes.

References

Lawati, M. H., Dennis, S., Short, S. D., & Abdulhadi, N. N. (2018). Patient safety and safety culture in primary health care: A systematic review. BMC Family Practice, 19(1). https://doi.org/10.1186/s12875-018-0793-7

Storesund, A., Haugen, A. S., Flaatten, H., Nortvedt, M. W., Eide, G. E., Boermeester, M. A., Sevdalis, N., Tveiten, Ø., Mahesparan, R., Hjallen, B. M., Fevang, J. M., Størksen, C. H., Thornhill, H. F., Sjøen, G. H., Kolseth, S. M., Haaverstad, R., Sandli, O. K., & Søfteland, E. (2020). Clinical efficacy of Combined Surgical Patient Safety System and the World Health Organization’s checklists in surgery. JAMA Surgery, 155(7), 562. https://doi.org/10.1001/jamasurg.2020.0989

Jan 10, 2023, 7:12 PM

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Hi Lydia, thanks for your post and for discussing the surgical checklist for patient safety. Serious complications and sometimes loss of life have resulted from surgical errors. The introduction of a surgical checklist helped alleviate the complications previously experienced. The most common surgical complications are related to surgical techniques, infections, and postoperative bleeding. A record of 48.6 to 60.7% reduction in equipment errors was achieved with the use of a preoperative checklist. Implementation and practice of good teamwork, communication, and consistency of care are essential in achieving improved patient safety.

The use of the World Health Organization Surgical Safety Checklist was noted to reduce complications from 11.0 to 7.0%, with a mortality drop from 1.5 to 0.8% in a global setting of eight hospitals in eight countries (Haugen et al., 2019). In another scenario, the WHO checklist was reported to have resulted in a reduction of surgical complications from 19.9 to 12.4% in the intervention group, and the concurrent length of stay was reduced by 0.8 days. As with any procedure, it is essential to implement and adhere to the protocol in its entirety to achieve the desired outcomes.

Reference

Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019). Impact of the world health organization surgical safety checklist on patient safety. Anesthesiology, 131(2), 420-425.

Jan 11, 2023, 11:28 PM

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Patient safety is a major concern in the healthcare system, and medical errors are the most significant threats in this regard. Generally, mistakes occur when one’s choice leads to negative or less desirable outcomes and in fact, the term “error” means to astray. The most frequent nursing students’ errors are related to hand hygiene and personal protection. In addition, the lack of enough skills and appropriate equipment are prevalent causes of nursing students’ errors.

Authorities in this field should attend to these errors in nursing education, clinical practice, and nursing studies in order to promote this profession in all of these three dimensions. Nurses play a crucial role in providing health care; however, the results of a study showed that 20% of nurses make at least one mistake during their working time. The factors leading to committing errors include heavy workload, a large number of patients, unstable patient status, nurses’ lack of adequate knowledge, improper working environment, and lack of support from and cooperation with experienced staff.

References

Mohsenpour M, Hosseini M, Abbaszadeh A, et al. Iranian paediatric nurses experience of nursing error: a content analysis. HK J Paediatr (New Series) 2017; 22: 97–102.

Jan 9, 2023, 4:45 PM

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I am unsure which stories touched me more, as I can see myself in every situation. For example, the doctor that accidentally administered the wrong blood due to inadequate onboarding processes could have easily avoided the mistake had he been familiar with the hospital’s procedures (Institute for Healthcare Improvement, n.d.). As many patients, including myself, have fallen victim to medical errors, we must begin to review the process (Institute for Healthcare Improvement, n.d.). Unfortunately, I am not optimistic when it comes to the nursing population, as it is likely that some will find it better to gloat about a colleague’s errors rather than focus on fixing the situation. However, the IHI curriculum pilot example shows that this process is ineffective in increasing patient safety but adds to the takeaways from the IHI lesson. The lesson examples that addressing errors systematically is the best approach (Institute for Healthcare Improvement, n.d.).

However, the assignment asks us to review the posted articles and provide a synopsis relevant to the topic; in this aspect, we know that ordering unnecessary labs increases costs (Haley & Fritz, 2019). In this case, simply empowering the nurses to assess and clinical judgment skills to assess residents for Urinary Tract Infections showed promise in reducing the orders for urine cultures (Haley & Fritz, 2019).

References

Haley, T., & Fritz, S. (2019). Treat the resident, not the urine: Using patient safety to reduce urinary tract infections and overuse of urine culture in long term care. American Journal of Infection Control, 47(6), S8. https://doi.org/10.1016/j.ajic.2019.04.148

Institute for Healthcare Improvement. (n.d.). Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement. https://my.ihi.org/

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