Application: Patient Safety Risks

As noted in the Institute of Medicine report, To Err is Human, “It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead” (Institute of Medicine, 1999, p. 15).

What are the most common—or most significant—risks to patient safety? How do these risks vary in different health care settings or with disparate groups of patients? What can be done to address these risks? You will explore these questions and more in this Application Assignment.

To prepare for this Application:

• Begin by brainstorming types of health care organizations and groups of patients (e.g., geriatric patients requiring chronic care, pediatric patients admitted for acute care). Identify a particular type of setting and/or patient population to help you pinpoint your focus for the following step.
• Review the National Patient Safety Goals, the CDC’s NHSN Web site, and the information on patient safety concerns presented in the other Learning Resources. Select a specific patient safety risk (e.g., patient falls, medication reconciliation) to focus on for this assignment.
• Analyze the systems errors and/or human factors errors that should be considered with regard to this safety risk.
• Reflect on related insights that could be gained from high-reliability organizations. What approaches do these organizations use that might be applicable within a health care organization?
• Consider the strategies and tools (e.g., Six Sigma, Lean) that could be used to assess and reduce this particular risk.
• Evaluate the potential benefits of patient and family involvement and steps that could be taken to ensure that they are included in this endeavor.

Note: To complete this Application Assignment, you will need to use the Learning Resources assigned in both Weeks 4 and 5.

The Assignment

Write a 4- to 5-page paper that addresses the following:

• Briefly summarize the patient safety risk you have selected, and provide a rationale for why it deserves particular attention.
• Analyze the influence of systems errors and human factors errors with regard to this risk.
• Discuss related insights that could be gained from high-reliability organizations and how they might be applied within a health care organization.
• Propose strategies and tools for assessing and reducing risk related to this safety issue.
• Describe how patients and patients’ families can be involved in addressing this issue.