Final_Project_Christine_Vaz_2_19_19.docx

Lastly the provider should deliver the message

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confidential setting where both patient/family members and the providers feel comfortable. Lastly, the provider should deliver the message respectfully, show empathy, and convey a sense of care. (ACOG, 2012) Disclosure: Reporting The Joint Commission is one of the most widely known accrediting agencies for institutions in the United States. They do not require the reporting of a “Sentinel Event”,
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ROOT CAUSE ANALYSIS & RECOMMENDATIONS 8 however, they encourage reporting as they not only support the organization throughout the course of the event but it also assists them in raising global awareness of measures that ensure patient safety. They identify a “sentinel event” as death, permanent harm, or severe temporary harm. The events of our case study would qualify as a “sentinel event” and therefore, resources including help with RCA would be available (JC, 2017). When it comes to regulatory agencies there are twenty four states that have mandatory reporting programs. Most of these programs are publically funded and vary in what constitutes as a reportable event. An example of this would be Massachusetts. They mandate that any “serious incident” occurring at a hospital is reported to the Division of Health Care Quality. They also require that physicians whom work in a health facilitates report “major incidents” in order to comply with the Patient Care Assessment. This is overseen by the Board of Registration in Medicine. Neither of these agencies require any root cause analysis to be reported (QUPS, 2019). The hospital’s most recent survey results revealed a positive response for supervisors promoting patient safety (75%) and management support for patient safety (70%). Based on these results we can postulate that patient safety is placed high on the priority list for this hospital. This is something that they believe should be promoted and built into the culture. A publication by the Joint Commission (2017, March 1) stated that “a leader who is committed to prioritizing and making patient safety visible through every date actions is a critical part of creating a true culture of safety” (p.1). The survey results reflect that employees of this hospital are taking notice of the commitment that their supervisors and managers have to patient safety. Knowing that their manager’s place a high value on patient safety allow the employees to feel supported in their efforts to promote a safer patient culture. As with all surveys, there are items that stand out for areas of improvement. At Union
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ROOT CAUSE ANALYSIS & RECOMMENDATIONS 9 Hospital these are staffing (25% positive result) and hand-offs/transitions (15%). These two vulnerable areas contradict supporting a culture of safety and need to be improved upon in order to reduce the possibility of adverse patient outcomes. Hospital staffing has become a largely debated topic, specifically nursing staff levels, in recent years. Some states have proposed laws that will mandate the nursing/patient ratios, including California for which has passed min. nurse to patient ratios (AHRQ, 2019). A low positive score on this survey question could indicate that
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  • Summer '18
  • Health care provider, attending physician, Quality and Patient Safety

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