1) I expected to learn about different methods of patient
safety that can be applied in a healthcare setting.
2) I learned about patient safety and became better informed
about Joint Commission standards. Patient safety is essential in healthcare so
patients can trust the care they receive and accidents or patient deaths can be
prevented. The Joint Commission (2015) has been an advocate of patient safety
for more than sixty years. They help health care organizations to improve the
quality and safety of the care they provide by providing patient safety-focused
initiatives and education for hospitals. This is aimed at encouraging and
supporting organizations in their efforts to make patient safety a continuous
priority. The Hippocratic Oath to “do no harm” requires physicians to abide by
professional ethical standards and treat patients safely (North, 2002). Nurses
have a code of ethics set forth by the American Nurses Association to have
wholeness of character and preserve their integrity. This is entirely applicable
to the patient situation when rendering care. Honesty, safety, and high ethical
standards are needed for the provision of safe patient-centered care by
practitioners.
The Joint Commission has set forth standards that hospitals
must abide by for accreditation. If practitioners do not adhere to these
standards, the hospitals can lose their accreditation, resulting in a loss of
business for the company. Therefore, hospitals consider patient safety a top
priority and much effort is aimed at quality improvement measures to create a
safer environment for patients.
3) The team discussion involved a situation of witnessing
another nurse place an unlabeled syringe filled with clear medication and an
empty heparin vial on a patient’s bedside table. We were to discuss as a team
if this was a violation of standards of care and what to do about it. We
discussed that the nurse was breaching Joint Commission standards of handling
medications safely. The best way to fix the problem was to confront the nurse
and assess their knowledge of safe medication handling. Likely the nurse was
poorly trained and needs more education involving standards of care. After
speaking with the nurse, discussing the situation with the charge nurse, and
then documenting an incident would be the next course of action. This way Risk
Management teams can be informed and develop new process and education aimed at
ensuring all staff are aware of safe medication handling policies and
procedures.
4) I plan to document incident reports about unsafe patient
experiences I witness or am involved in (hopefully I am not involved in any
though!). This can lead to better process improvement system designs. I also
plan to implement Just Culture in my own process and not shame or cast blame at
practitioners who do make mistakes. They need to be supported and given more
education to prevent future mistakes. The system needs to be fixed as well to
prevent future patient fatalities or errors.
5) I enjoyed the material covered—as always, it was very
insightful for me. I feel I have gained better ways to confront individuals
about patient safety concerns, instead of assuming things and casting blame. I
have also been better educated about Joint Commission standards and feel more
informed about online resources available to me that promote and outline
patient safety standards.
References
North, M. (2002). Greek medicine: The Hippocratic Oath. National Library of Medicine. Retrieved from https://www.nlm.nih.gov/hmd/greek/greek_oath.html
The Joint Commission (2015).
Patient safety and quality. Retrieved online from http://www.jointcommission.org/topics/patient_safety.aspx
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