Work Site Interview

Instructions:
Meet with the Risk Management, Quality Assurance, Accreditation or Safety Officer at your current work site
II.    Explore Continuous Quality initiatives in your work setting
III.   Attend a committee meeting or in-service
IV.   Discuss processes for Analysis of errors
      a.    Root Cause Analysis (RCA)
      b.    Failure Mode Effects Analysis (FMEA)
      c.    And Serious Safety Events
V.Create a summary or critique of this visit, interview, meeting attendance, observation, or other investigative activity. Minimum of one page and      maximum of four pages excluding cover page (Reference page see APA guide for personal interview)
VI.Examine and evaluate your interpretation of your work settings quality improvement Processes
VII.         Be creative, and Enjoy the synthesis of your readings
VIII. No Safe Assign required
IX. Professional APA

Introduction

In every work environment, there are various continuous quality initiatives in place to improve organization’s product or service quality. For instance, in the United States, many patients have been losing lives due to serious and avoidable medical errors or safety events (Muething et al., 2012). For this reason, it is crucial to understand how these avertable medical errors or safety events can be prevented or eliminated. There are factors involved in the process of analyzing particular errors in an organization. This paper focuses on two processes of error analysis (Root Cause Analysis (RCA) and Failure Mode Effects Analysis (FMEA)) to address unnecessary medical errors (Serious Safety Events (SSE)). SSE in a healthcare setting is defined as any deviance from usually-accepted practice that may affect the patient and causes serious harm or sometimes death (Hoppes and Mitchell, 2014). RCA is a technique used to determine the root cause of certain events. FMEA is a logical and proactive method for evaluating a process to investigate where and how the process may fail (Institute for  Healthcare Improvement, par. 2). Further, FMEA assesses the comparative impact of various failures to ascertain the part of the process that should be changed. Therefore, RCA and FMEA are conducted after an event (damage) has occurred (University of Minnesota, par. 3). However, they prevent recurrences of the event. The researcher conducted an interview with a risk management officer of the American Society for Healthcare Risk Management to establish the root cause of deaths related medical errors in the USA.

Summary of the interview

American Society for Healthcare Risk Management prioritizes the elimination of preventable harm to the United State citizens. The society concentrates on several factors to attain this.

In order to appreciate avoidable harm, it is necessary to determine the patient safety and to ascertain whether the suggested solution is effective (Story and Nguyen, 2011). Normally, measurement of avertable harm has been always a challenge. Since the definition of harm varies across various data capture methods. These encounters make it cumbersome to classify alleviate primary causes of harm. Therefore, it affects the ability of the society to identify and prove the efficacy of patient safety risk management solutions that decrease medical errors and preventable serious safety events. 

Measures push for improvement, inform patients and effect payment. Both public and private payers apply measures to make a decision on the health providers they should contract and to enhance improvements in healthcare (Hoppes and Mitchell, 2014). Hence, describing, categorizing and emphasizing on harm prevention is critical for any practical risk management program.

To prevent or eliminate numerous deaths related medical errors. American Society for Healthcare Risk Management has come up with Getting to Zero.  Getting to Zero is a Serious Safety Events initiative, which emphasizes on event investigation stages. The core part of the investigation process is to establish harm-score. This always prompts an organizational response and risk management. Therefore, without proper and accurate harm-score examination, the chances for applying operational response may be wanting.

American Society for Healthcare Risk Management developed Harm Classification Tool to help risk managers and health care leaders to group an event when deviation happens. Additionally, the tool aids them to ascertain what actions are suitable for a particular event. The tool supports the American Society for Healthcare Risk Management Harm Scale. This tool classifies levels of harm into three categories: Serious Safety Event, Safety Event, and Pre-Patient Event. In case of Serious Safety Event and Safety Event, the occurrence reaches the patient with diverse levels of harm that are likely to occur. On the other hand, Pre-Patient Event is informal harm mitigation barriers in place to safeguard the patient.

Serious Safety Event which is within the scope of this paper consists of two levels of harm. They include severe permanent or temporary harm (SSE-2) and death (SSE-1). An event is categorized SSE-1 when an unexpected death occurs, which does not have relation with the patient’s underlying condition. An incident is labeled SSE-2 when the patient’s outcome is symptomatic and requiring life-saving interventions. Some of these interventions often lead to either temporary or permanent loss of function. For both scenarios (SSE-2 and SSE-1) RCA which calls for FMEA is always recommended to establish the cause of an event.

Conclusion

Currently, there are many deaths related to medical errors in the USA due to improper mitigation approaches in place. However, the American Society for Healthcare Risk Management has proper strategies (RCA and FMEA) in place to curb thousands of deaths that occur as medical errors. Thus, hopefully this peril would be successfully solved.

References

Hoppes, M., & Mitchell, J. (2014). Serious Safety Events: A focus on harm classification: Deviation in care as a link Getting to Zero White Paper Series-Edition No. 2. Retrieved October 17, 2017, from http://www.ashrm.org/pubs/files/white_papers/SSE-2_getting_to_zero-9-30-14.pdf.

Institute for  Healthcare Improvement. (2017, October 11). Failures Modes and Effects Analysis(FMEA). Retrieved October 17, 2017, from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx.

Muethigi, S., E., Goudie, A., Schoetteker, P., J., Donnely, L., F., Goodfriend, M., A., Bracke, T., M., Brady, P., W., Wheeler, D., S., Anderson, J.,M.,  & Uma, R., K.(2012). Quality improvement initiative to reduce Serious Safety Events and improve patient safety culture. Paediatrics, 130(2), e423-e431.

Story, M., F., & Nguyen, Q. (2011). Identifying use errors and human factors approaches to controlling risks. Retrieved October, 17 2017 from http://bit.ly/2g9tkGm.

University of Minnesota. (2017, October 11). Overview of error analysis. Retrieved October, 17 2017 from http://carla.umn.edu/learnerlanguage/error_analysis.html.