Patient safety issues fall into several categories: Wrong-Site Surgery, Medication Errors, Health Care-Acquired Infections, Falls, Readmissions , and Diagnostic Errors. Step 1

Task Module 2
Task: Patient Safety
Patient safety issues fall into several categories: Wrong-Site Surgery, Medication Errors, Health Care-Acquired Infections, Falls, Readmissions , and Diagnostic Errors. Step 1
Let’s take a look at some common safety issues.
Use these resources to learn more about patient safety issues in each category. Then investigate actual safety issues in the field.
http://www.jointcommission.org/sentinel_event.aspx Read Ch. 11 of The Healthcare Quality Book: Vision, Strategy and Tools
Read Ch. 8 of Managerial Ethics in Healthcare: A New Perspective
Review AHRQ’s Patient Safety Primer
Read Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, Second Edition
Guiding Questions
What categories do safety issue fall into?
List safety issues.
Who is at fault?
How could the safety issue have been prevented?
Step 2: Go on a Field Trip
Now, visit a healthcare setting such as a community hospital, large urban health center, or long term care facility.
First make an appointment to talk to the Healthcare Administrator. Before your appointment, sit in an area of the hospital open to visitors for at least 30 min and watch the activity.
What do you observe about how the hospital operates?
Who do you see?
Do you notice any issues that could lead it issues with safety?
What about patient confidentiality and safety of patient information?
Interview the healthcare administrator about patient safety and quality care.
What issues do they have?
What special practices do they have in place to ensure safety and quality?
Assignment:
Submit answers to the guiding questions in Step 1 and 2.
Lesson Module 2
Lesson
Activity 1: Organizational Culture of Safety
Read the case studies. Both are contained in the same document. Reflect on the guiding questions.
Case Study 1: Accelerating Patient Safety Improvement by strengthening the culture of safety- Sentara Norfolk General Hospital
Case Study 2: Creating a Culture of Safety in the U.S. Department of Veterans Affairs Health Care System
Guiding Questions
1. What issues of safety existed that are common to most hospitals?
2. What best practices did the hospitals put into place to address safety?
3. What change was seen as a result of the best practices?
Activity 2: Protocol
Based on what you learned from the field trip and from studying the case studies, develop a series of protocols and procedures for Mercy Hospital to deal with safety.
Discussion 2
Wrong patient, wrong site, wrong procedure events have decreased in most hospitals. However, they continue at Mercy. What is the most common reason this is occurring? What can be done to decrease this sentinel event? And who should be responsible?