Chapter 14 Medical Errors An Ongoing Threat To Quality Health Carec ✓ Solved

Chapter 14 Medical Errors: An Ongoing Threat to Quality Health Care Definitions Medical errors: adverse events that could have been prevented given current state of medical knowledge Medication error: preventable event causing or leading to inappropriate medication use or patient harm Medication in control of health care professional, patient, or consumer Adverse events: adverse changes in health occurring as a result of treatment Adverse drug event when medications involved Seminal Research and Medical Errors #1 Benchmark study by Brennan et al. (1991) Study by Thomas et al. (1999) Study by Leape et al. (1991 and 1994) Seminal Research and Medical Errors #2 “To Err Is Human†by the Institute of Medicine (IOM) Death due to medical errors: possibly eighth leading cause of death in 1999 More people die yearly from medical errors than from motor vehicle accidents, breast cancer, or AIDS Examination of types of errors: adverse events with pharmaceutical agents (potentially preventable) Studies confirming IOM figures Confirmation of scope of medical errors in follow-up report by IOM Seminal Research and Medical Errors #3 IOM recommendations: National goal to reduce medical errors by 50% over 5 years Four-pronged approach to reducing medical mistakes nationwide (see Box 14.1) National focus Identification of, and learning from, errors Elevation of standards, expectations for improvement Implementation of safe practices Question #1 Is the following statement true or false?

Adverse events result from treatment. Answer to Question #1 True Adverse events are defined as adverse changes in health that occur as a result of treatment. Work to Achieve IOM Goals #1 Quality Interagency Coordination Task Force (1998) Coordination of federal agencies providing health care services Evaluation of IOM recommendations Development of strategies for identifying threats to patient safety, reducing medical errors Final report delivered in February 2000 Work to Achieve IOM Goals #2 National Forum for Health Care Quality Measurement and Reporting (2017) The National Quality Strategy: Aims, Priorities, and Levers Aims Better care Healthy people/Healthy communities Affordable care Work to Achieve IOM Goals #3 The National Quality Strategy: Aims, Priorities, and Levers (see Box 14.3) Six priorities Eight levers Work to Achieve IOM Goals #4 Joint Commission 2017 National Patient Safety Foundation (see Box 14.4) Improve patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery Work to Achieve IOM Goals #5 The Joint Commission Comprehensive database of sentinel events Root cause analysis; Sentinel Events Policy Failure mode and effects analysis (FMEA) Work to Achieve IOM Goals #6 Centers for Medicare and Medicaid Services (formerly HCFA) Medicare Quality Initiatives Pay for Performance (quality-based purchasing) Physician Quality Reporting Initiative; became Physician Quality Reporting System with passage of Affordable Care Act of 2011 PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (Quality Payment Program, 2017) Work to Achieve IOM Goals #7 Centers for Medicare and Medicaid Services (formerly HCFA) Medicare Improvements for Patients and Providers Act (2008) “Never events†(see Box 14.5) Work to Achieve IOM Goals #8 Institute for Healthcare Improvement Highlighting of evidence-based best practices Disciplined research and development processes, prototyping projects Facilitation of further research, adaptation, and adoption of quality improvement strategies Health care report cards Question #2 The National Priorities Partnership evolved out of which of the following?

A. Quality Interagency Coordination Task Force B. Centers for Medicare and Medicaid Services C. National Forum for Health Care Quality Measurement and Reporting D. The Floyd D.

Spence National Defense Authorization Act of 2001 Answer to Question #2 C The National Priorities Partnership developed from the work of the National Forum for Health Care Quality Measurement and Reporting. Culture of Safety Management Patient safety: one of nation’s most pressing challenges Mandate for every health care organization IOM final recommendation: implementation of safe practices at delivery level Six Sigma Approach Culture of safety management at institutional level Sigma: statistical measurement reflecting product or process performance Higher sigma values = better performance Historically, health care aiming for three-sigma processes instead of six Mandatory Reporting of Errors Mandatory reporting system for medical errors, adverse events at national, state levels As of 2014, at least 26 states requiring hospitals and/or other medical facilities to report serious medical errors Need for increased mandatory reporting at institutional level and by individual providers Possible fear of legal suits or disciplinary measures as barrier for greater disclosure and reporting Legal Liability and Medical Error Reporting Medical liability system + litigious society: potential barriers to systematic efforts to uncover, learn from mistakes Patient Safety Improvement Act (2002) Patient Safety and Quality Improvement Act of 2005 Proposed federal legislation to protect voluntary reporting of ordinary injuries, “near misses†Leapfrog Group Need for implementation of evidence-based standards such as Computerized physician (or prescriber) order entry (CPOE) Leapfrog developed evaluation tool Evidence-based hospital referral (EHR) Intensive-care-unit physician staffing (IPS) Question #3 Is the following statement true or false?

A sigma value of three indicates lower performance than a sigma value of five. Answer to Question #3 True A sigma value is a statistical measurement that reflects performance. Thus, the higher the sigma value, the better the performance. Bar Coding Medications Reduction in point-of-care medication errors National drug code number for all prescription, OTC meds used in hospitals Bar coding + CPOE = increased ability to follow “five rights†of medication admin Changing Organizational Culture Quality and Safety Education for Nurses (QSEN) project Knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care system KSA—better able to identify potential errors and intervene before errors occur Organizational cultures needing to remove blame from individual and focus on how organization can be modified to reduce likelihood of errors “Just culture†or “culture of safety management†Patient Safety Solutions WHO’s Word Alliance for Patient Safety and the Collaborating Centre packaged nine effective solutions called patient safety solutions to reduce health care errors WHO (2017) initiated its third Global Patient Safety Challenge: Medication Without Harm See Box 14.6 Question #4 Which of the following would most likely be most significant in promoting a culture of safety management?

A. Mandatory reporting of errors B. Six Sigma approach C. Bar coding meds D. Removal of blame Answer to Question #4 D Although mandatory reporting of errors, a Six Sigma approach, and bar coding meds are important in promoting a culture of safety management, perhaps the most significant change that must occur is that organizational cultures must be created that remove blame from the individual and focus on how the organization can be modified to reduce the likelihood of errors occurring in the future. End of Presentation Question 1: Discuss the regulatory compliance requirements that the “State Grid†has to meet and the corresponding security, privacy, and records management functions that would need to be enabled for that organization. (At least 250 Words) Question 2: Discuss the regulatory compliance requirements that the “Tesco†has to meet and the corresponding security, privacy, and records management functions that would need to be enabled for that organization. (At least 250 Words) Requirements At least 250 Words to answer each question APA 7 At least 2 references for each question No plagiarism

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Medical Errors: An Ongoing Threat to Quality Health Care

Medical errors represent a significant and ongoing threat to patient safety and the quality of health care. Defined as preventable adverse events that occur despite the availability of current medical knowledge, these errors can involve medication mistakes, misdiagnosis, or errors in treatment. In the context of today's health care system, understanding the regulatory compliance requirements that various organizations must meet is crucial to improving patient safety and reducing the incidence of medical errors.

Regulatory Compliance for State Grid

The "State Grid" likely refers to a public utility or organization that provides essential services. In the case of health care organizations, compliance with various laws and regulations is mandatory to ensure the protection of patient information and the safe delivery of services. One of the foremost regulatory frameworks that State Grid must comply with is the Health Insurance Portability and Accountability Act (HIPAA), established in 1996. HIPAA sets the standard for protecting sensitive patient data and mandates that organizations implement adequate administrative, physical, and technical safeguards (U.S. Department of Health & Human Services, 2013). Compliance requires developing a privacy policy that outlines the handling of protected health information (PHI), as well as offering training for employees to foster a culture of compliance.
Regarding security regulations, the State Grid must develop protocols to handle breaches of patient data effectively, including notification requirements and risk assessments. This is particularly crucial in securing electronic health records (EHRs), which are frequently targeted for cyberattacks (Davis et al., 2019). Furthermore, records management functions must be established to ensure accurate documentation of patient interactions and care processes, which can facilitate tracking medication orders and treatment plans.
To achieve compliance with Health Information Technology for Economic and Clinical Health (HITECH) Act, the State Grid must ensure that electronic data exchanges adhere to stringent standards to protect against unauthorized access, requiring mechanisms like audit logs and access controls (Kellermann & Jones, 2013). In implementing these regulations, training programs for staff should emphasize the importance of data integrity to prevent medication errors and ensure patient safety.
In summary, the regulatory compliance requirements for the State Grid involve ensuring adherence to HIPAA and HITECH, as well as implementing comprehensive strategies for security, privacy, and records management. Effective implementation of these functions can significantly diminish the risk of medical errors and improve overall health care quality.

Regulatory Compliance for Tesco

For a company like "Tesco," which operates in the retail and grocery sectors, compliance with various laws and regulations is similarly critical, albeit in a different context than health care. One of the most significant regulations that Tesco must adhere to is the General Data Protection Regulation (GDPR), enacted in the European Union in 2018. GDPR stipulates stringent requirements for the processing and protection of consumer data, particularly personal and financial information (Information Commissioner's Office, 2019). Tesco must ensure that customer data is handled transparently, with explicit consent obtained before personal data is processed.
Moreover, Tesco is also subject to Consumer Rights Act 2015, which outlines obligations concerning product safety and consumer protection (UK Government, 2015). This law requires the company to ensure that all goods are safe to use and match the description provided at the time of sale. Failure to comply can result in recalls, fines, and damage to brand reputation—a potential increase in medical errors could occur as a result of compromised patient care stemming from incorrectly processed health-related products or prescriptions.
Tesco must also maintain a secure and compliant records management system that can track purchases, returns, and complaints effectively. Implementing stringent access control measures ensures that not just anyone can access sensitive information (Chou et al., 2020). This aspect of compliance holds particular importance if the company enters the health sector by offering health-related products or services, where adherence to health regulations becomes crucial.
To summarize, Tesco’s regulatory compliance requirements encompass adherence to GDPR, Consumer Rights Act, and robust security measures aimed at protecting customer information. Proper implementation of these functions is vital in mitigating risks associated with errors, ultimately supporting operational efficacy and consumer trust.

Conclusion

Both State Grid and Tesco play significant roles in their respective sectors, and understanding and addressing the regulatory compliance requirements pertinent to each organization is vital for ensuring safety and quality in the services they provide. For the State Grid, the emphasis is on protecting patient health information and ensuring a culture of safety in patient care, while for Tesco, the focus is on data protection and consumer rights. Both organizations can significantly minimize the occurrence of errors by adhering to these regulations while implementing strong security and records management practices.

References

1. Chou, T., Chen, C.-H., & Chang, H. H. (2020). Factors affecting the implementation of information security management. International Journal of Information Security, 19(3), 319-330.
2. Davis, J., Cummings, R., & Chaudhary, R. (2019). Cybersecurity Compliance: A Comprehensive Guide for Navigating Regulations. Health Management, Policy and Innovation, 4(2), 14-22.
3. Information Commissioner's Office. (2019). Guide to the General Data Protection Regulation (GDPR). Retrieved from https://ico.org.uk/for-organisations/guide-to-data-protection/
4. Kellermann, A. L., & Jones, S. S. (2013). What It Will Take To Achieve The As-yet Unfulfilled Promises of Health Information Technology. Health Affairs, 32(1), 63-70. doi:10.1377/hlthaff.2012.1080
5. UK Government. (2015). Consumer Rights Act 2015. Retrieved from https://www.legislation.gov.uk/ukpga/2015/15/contents/enacted
6. U.S. Department of Health & Human Services. (2013). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
7. Leape, L. L., & Berwick, D. M. (2005). Five Years After To Err Is Human: What Have We Learned? JAMA, 293(19), 2395-2401.
8. Brennan, T. A., Leape, L. L., & Laird, N. M. (1991). Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324(6), 370-376.
9. Thomas, E. J., & Brennan, T. A. (1999). Incidence and Types of Adverse Events and Negligence in Hospitalized Patients: A Consensus Study. JAMA, 287(20), 2696-2702.
10. Institute of Medicine (IOM). (1999). To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press.