BHA-FPX4004-Patient Safety and Quality Improvement in Health Care

Risk Management Policy & Procedure & Analysis

School of Nursing and Health Sciences, Capella University

BHA-FPX4004- Patient Safety and Quality Improvement in Health Care

June 2, 2023

 PART 1

Risk Management Policy and Procedure

Purpose Statement

A risk management program is essential for advancing the strategic safety and quality objectives of an organization. By implementing a comprehensive risk management program, the organization can proactively identify, assess, and mitigate potential threats to patient safety, employee well-being, and organizational reputation. The primary objective of the risk management program is to foster a culture of safety and continuous improvement throughout the organization by promoting effective risk identification, analysis, and control measures. This program seeks to reduce adverse events, prevent medical errors, and improve the quality of patient care overall. A comprehensive risk management program, according to Renn (2020), supports the organization's commitment to regulatory compliance, accreditation standards, and legal requirements, ensuring that the organization operates safely and ethically. By systematically and consistently addressing risks, the organization can attain its strategic objectives of providing high-quality care, reducing adverse events, and preserving a secure and trustworthy healthcare environment for all stakeholders.

Key Risk Management Terms

Risk prevention: Risk prevention refers to the proactive measures taken to avoid or minimize the occurrence of risks or potential harm. It involves identifying potential risks, implementing strategies, and creating safeguards to prevent adverse events or incidents from happening in the first place.

Risk reduction: Risk reduction involves actions taken to lessen the severity, likelihood, or impact of identified risks. It focuses on mitigating the potential harm or negative consequences associated with risks through various control measures, interventions, and process improvements.

Regulatory compliance: Regulatory compliance refers to the adherence and conformity to laws, regulations, guidelines, and standards set forth by regulatory bodies, government agencies, or accreditation organizations. It involves ensuring that the organization operates within the legal framework and meets the required standards of practice in order to maintain quality, safety, and ethical standards.

Patient safety: Patient safety encompasses the efforts and measures taken to prevent harm to patients during the delivery of healthcare services. It involves creating a safe and secure environment, minimizing risks, and implementing strategies to reduce medical errors, adverse events, and healthcare-associated infections. Patient safety focuses on enhancing the overall quality of care and promoting a culture that prioritizes patient well-being.

Adverse event: An adverse event refers to an unintended, harmful, and undesired outcome that occurs during or after the delivery of healthcare services. It can result from medical errors, system failures, or complications related to treatment, procedures, medications, or devices. Adverse events can range from mild to severe and may have a significant impact on patient health and well-being.

Near miss: A near miss is an event or situation that could have resulted in harm or an adverse event but did not cause harm to the patient. It is an opportunity for learning and improvement as it indicates a potential vulnerability in the system or process that could lead to future adverse events. Near misses should be reported, investigated, and addressed to prevent future occurrences and improve patient safety.

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Major Risk Categories and Risk Identification Techniques

Several main risk categories in a healthcare organization require attention for effective risk management. These categories consist of financial, human capital, and clinical hazards. Financial hazards entail the potential for a company to incur losses or experience adverse financial effects. The organization can employ risk identification techniques such as financial analysis, internal audits, and external benchmarking to identify and manage financial risks. Financial analysis involves monitoring and analyzing financial statements, budgets, and performance indicators on a regular basis in order to identify areas of financial vulnerability or potential hazards. Internal audits assist in evaluating financial practices, invoicing procedures, and classification precision in order to detect errors or illicit activity. External benchmarking enables the organization to compare its financial performance to industry benchmarks, thereby identifying improvement opportunities and potential hazards (Moore & Patton, 2019).). Human capital risks include employment, attrition, competency, and employee engagement. To identify and manage human capital risks, the organization may employ risk identification techniques like employee surveys and personnel analysis. Employee satisfaction and engagement surveys provide valuable insights into potential hazards or areas of concern within the workforce. According to Rao et al (2020) staffing analysis involves evaluating staffing levels, skill balance, and attrition rates in order to identify potential hazards associated with insufficient staffing, skill deficits, or high turnover. 

Clinical risks include potential patient injury or adverse events caused by healthcare processes or interventions. Clinical risk identification methods may include incident reporting, root cause analysis, and clinical audits. Incident reporting systems permit healthcare professionals to record and report adverse events, near misses, and errors that occur during patient care. Root cause analysis facilitates the implementation of preventative measures by identifying the underlying causes and contributing factors of adverse events (Rao et al., 2020). Clinical audits consist of examining clinical processes, protocols, and outcomes to identify potential hazards or development opportunities.

To comprehensively identify potential organizational risks, the organization can adopt a multifaceted strategy. This may involve employing techniques for concurrent risk identification, such as real-time monitoring, safety protocols, and safety huddles, to identify risks as they occur. Retrospective methods, such as incident reporting and data analysis, permit the identification of trends and patterns in adverse events and near misses. Rao et al.(2020) states that the organization can implement proactive risk identification strategies, such as safety assessments, risk assessments, and process mapping, to identify vulnerabilities and voids in processes or systems that may pose risks. By employing a combination of risk identification techniques and incorporating them into the risk management strategy, healthcare organizations can effectively identify and mitigate potential risks in the financial, human capital, and clinical domains, thereby enhancing patient safety, quality of care, and organizational outcomes.

Risk Manager’s Role In Program Implementation and Compliance

The risk manager plays a crucial role in the implementation and compliance of the risk management program within a healthcare organization. They are responsible for overseeing the development, implementation, and monitoring of risk management policies and procedures. By identifying and analyzing potential risks, the risk manager can develop strategies to mitigate those risks and promote a culture of safety throughout the organization (Hammerschmidt & Manser, 2019). Their expertise in risk assessment and management allows them to proactively address risks, minimize adverse events, and enhance patient safety. Moreover, the risk manager ensures that the organization stays compliant with regulatory requirements and industry best practices, reducing legal and financial liabilities. A study by Allegranzi. (2018) exemplifies the positive impact of a risk manager on a healthcare organization's risk management program. The research showed that the presence of a risk manager was associated with improved safety practices, increased staff awareness of risks, and enhanced patient safety outcomes, highlighting the significant contribution of risk managers in effective risk management.

Part 2 – Application of Risk Management Principles – Specific Incident

In this section of the paper, we will discuss the importance of a risk management program to healthcare organizations. The complex and high-risk nature of the healthcare industry necessitates a systematic approach to identify, assess, and mitigate risks in order to ensure the safety of patients, employees, and the organization as a whole. We will explore the important elements of a risk management program, the reasons why it is crucial for healthcare organizations, and the potential organizational impact of not having a robust risk management program in place. By understanding the significance of risk management, healthcare organizations can prioritize the implementation of effective strategies to mitigate risks and ensure the delivery of safe and high-quality care.

Risk Description

The specific risk being analyzed in this scenario is a medication error. Independence Medical Center is where I am employed at the present time in the role of risk management. Three incidents happened lately that may have been dangerous for my company. A HIPAA/privacy breach, a prescription error, and a mistake in patient identification were all examples. Although I had previously evaluated the potential dangers posed by a prescription mistake, I decided to devote more time to the topic this time around. To quickly review, on the 8th floor pediatric unit, there were two patients who shared a name with another kid in the room right across from theirs. A pharmaceutical mix-up happened during their hospital stay because a patient identification mistake was made. B. Moore's mother witnessed two employees making an improper connection between the employee's daughter and the patient the day following the prescription mistake while working at the front desk. 

  To address the risk of medication errors, healthcare organizations should adopt various risk management strategies. One effective approach is medication reconciliation, which involves a systematic process for comparing a patient's medication orders at different points of care to ensure accurate and up-to-date information. This helps identify discrepancies and reduces the likelihood of errors during transitions of care. Another crucial strategy is the implementation of barcode medication administration (BCMA) systems, which utilize barcodes on medications and patient identification to verify the right medication, dose, route, and patient before administration, minimizing the risk of administration errors.

Healthcare organizations should prioritize staff education and training programs that emphasize medication safety principles, error prevention strategies, and effective communication among healthcare professionals. Leveraging technology, such as electronic prescribing systems and computerized physician order entry (CPOE), can enhance accuracy and reduce errors associated with illegible prescriptions and incorrect dosages. 

Risk Implications

If the risk of medication errors, specifically the identified medical error, is not adequately addressed, it can have significant implications for patients, employees, and the healthcare organization as a whole. For patients, the consequences of unaddressed medication errors can range from mild to severe. Patients may experience adverse drug reactions, worsening of their medical condition, delayed recovery, or even death. The lack of proper risk management increases the potential for administering incorrect medications or dosages, which can lead to harmful side effects or ineffective treatment (Sanders, 2016). Patients may lose confidence in the healthcare system, resulting in decreased satisfaction and trust in the organization's ability to provide safe and high-quality care.

Employees involved in the medication administration process may also face negative consequences. Their professional reputation can be compromised, leading to emotional distress, guilt, and potentially legal implications. A culture of blame and fear can develop if the organization fails to address the risk, hindering open communication and reporting of errors (Moore & Patton, 2019). This can impede the organization's ability to learn from mistakes and implement necessary improvements in medication safety. From an organizational perspective, the impact of unaddressed medication errors can be detrimental. It can result in reputational damage, legal liabilities, financial losses, and increased healthcare costs. The organization may face lawsuits, regulatory penalties, and decreased patient volume as word spreads about the safety concerns. Moreover, the organization's quality indicators and patient satisfaction scores may be negatively affected, leading to a decline in overall performance and competitiveness (Moore & Patton, 2019).

To mitigate these risks, evidence-based risk management strategies and techniques should be implemented. This includes establishing comprehensive medication safety protocols, implementing technology-based systems such as barcoding and electronic prescribing, conducting regular medication reconciliation processes, providing staff training on medication safety, encouraging open reporting and learning from errors, and continuously monitoring and evaluating the effectiveness of risk management efforts. By actively addressing the risk of medication errors through these strategies, the organization can significantly reduce the potential harm to patients, mitigate negative implications for employees, and safeguard its reputation and financial well-being.

Evidence-Based Risk Management Strategies To Reduce/Eliminate

To eliminate or reduce the risk of medication errors, healthcare organizations can implement evidence-based risk management strategies (Zhou et al., 2018). This includes analyzing incident reports to identify patterns and root causes of errors, conducting a drill down analysis to determine contributing factors, and implementing targeted interventions. Medication reconciliation processes should be established to ensure accurate medication administration during care transitions. Barcode scanning technology and electronic prescribing systems can be employed to minimize errors and improve medication accuracy (Rodziewicz et al, 2020). Comprehensive training and education programs should be provided to healthcare professionals, focusing on medication safety protocols and proper administration techniques. Continuous quality improvement efforts, such as regular audits and performance improvement projects, are essential to monitor compliance and identify areas for improvement. Leadership support, collaboration among healthcare professionals, policy development, monitoring and evaluation, and ongoing education are crucial steps to implement the risk reduction plan effectively. By adopting these evidence-based strategies and following the implementation steps, healthcare organizations can enhance patient safety and reduce the occurrence of medication errors.

Importance of a Risk Management Program

A risk management program is of utmost importance to health care organizations for several reasons. Firstly, it helps identify and mitigate potential risks, ensuring the safety of patients, employees, and the organization as a whole. By proactively assessing and managing risks, organizations can prevent adverse events, medical errors, and harm to patients. Secondly, a risk management program promotes compliance with regulatory requirements and industry standards. It helps organizations stay up-to-date with changing regulations, guidelines, and best practices, reducing the risk of legal and financial liabilities. This is especially critical in the healthcare industry, where strict regulatory oversight exists to ensure patient safety and quality of care (Zhou et al., 2020). Furthermore, a risk management program fosters a culture of safety within the organization. It encourages open communication, reporting of incidents and near misses, and the implementation of corrective actions. This creates a learning environment where continuous improvement is prioritized, leading to enhanced patient outcomes and employee satisfaction.

Some important elements of a risk management program include risk assessment and analysis, risk mitigation strategies, incident reporting and investigation, staff training and education, policy development, and performance monitoring. These elements work together to identify, evaluate, and control risks, allowing organizations to make informed decisions and take appropriate actions. The organizational impact of not having a risk management program can be significant. Without a structured approach to risk management, organizations are more vulnerable to adverse events, medical errors, and safety breaches (Renn,2020). This can result in patient harm, legal consequences, damage to reputation, decreased staff morale, and financial losses. Furthermore, the absence of a risk management program may lead to a lack of compliance with regulatory requirements, putting the organization at risk of sanctions or penalties. In summary, a risk management program is vital for health care organizations to ensure patient safety, maintain regulatory compliance, promote a culture of safety, and safeguard their reputation and financial stability. By implementing an effective risk management program, organizations can proactively manage risks, enhance patient care, and create a safe and resilient healthcare environment.

References

 Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention: proceedings of the lancet conference on healthcare-associated infections. J Hosp Infect. 2009;73:305–15. https://doi.org/10.1016/j.jhin.2009.04.019.

Hammerschmidt, J., & Manser, T. (2019). Nurses’ knowledge, behaviour and compliance concerning hand hygiene in nursing homes: a cross-sectional mixed-methods study. BMC health services research, 19(1), 1-13. https://doi.org/10.1007/s00103-011-1363-5

Han, Y., Kim, J. S., & Seo, Y. (2020). Cross-sectional study on patient safety culture, patient safety competency, and adverse events. Western Journal of Nursing Research, 42(1), 32-40. https://doi.org/10.3390/medicina55090553

Moore, Z. E., & Patton, D. (2019). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, (1). https://doi.org/10.1002/14651858.CD006471.pub4

Rao, C., Liu, M., Goh, M., & Wen, J. (2020). 2-stage modified random forest model for credit risk assessment of P2P network lending to “Three Rurals” borrowers. Applied Soft Computing, 95, 106570. https://doi.org/10.1016/j.asoc.2020.106570

Renn, O. (2020). Risk communication: Insights and requirements for designing successful communication programs on health and environmental hazards. In Handbook of risk and crisis communication (pp. 80-98). Routledge. https://doi.org/10.3390/ijerph17113869

Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://doi.org/10.3390/medicina55090553

Sanders, P. (2016). Seven strategies for partnering with risk managers. Nursing Management (Springhouse), 47(10), 18–19. https://doi.org/10.1097/01.NUMA.0000499579.61119.64.

Tinanoff, N., Baez, R. J., Diaz Guillory, C., Donly, K. J., Feldens, C. A., McGrath, C., ... & Twetman, S. (2019). Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. International journal of paediatric dentistry, 29(3), 238-248. https://doi.org/10.1111/ipd.12484

Zhou, S., Kang, H., Yao, B., & Gong, Y. (2018). Analyzing Medication Error Reports in Clinical Settings: An Automated Pipeline Approach. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371341