Patient Safety Andperformance Improvement Integration Paper


Scenario: There is a recommendation from the Institute for Safe Medication Practices (ISMP) that some high risk medications should always have a double check before being administered. The Director of Perioperative Services has identified that there have been several near misses involving heparin solutions on the sterile field and that the operating room staff should embrace this recommendation. Surgical Tech, Edward, is nearing completion of his orientation. The usual staffing pattern calls for him to scrub and his preceptor, Faith, who is an RN to circulate. The case is considered “minor”. It is the insertion of a mediport. There is a shortage of staff to do lunch reliefs so the team leader for the pediatric service, Mary, assigns herself to circulate on this case. The team leader Mary has a history of intimation of new staff and a sense that the new rules do not add any value to patient safety and only take away from efficiency. The team leader usually provides the second check of calculations for circulating nurses in her assigned area. Mary calculates the dosages of heparin infusion for both the irrigation and the flush doses on the sterile field. The surgical tech, Edward, accepts the meds and does not question Mary as he is nervous that he is alone without his usual preceptor and does not want to anger the team leader. Mary documents both his initials and those of the absent circulating nurse in the perioperative record. Upon return from lunch, the circulating nurse, Faith, reviews the documentation for completeness before signing off the record. She notices her initials on the medication check and informs the nurse manager

Given the above scenario, apply the Just Culture and Human Factors frameworks to develop a proposal on how to address the scenario. Include the following:

  • Brief introduction with synopsis of scenario and framing the proposal by describing analysis methods/models to be used and intended result (to provide improvement recommendations)
  • Just Culture assessment of the level of intent/risk of behaviors and your rationale
  • Provide specific performance management recommendations for the person(s) involved in the incident:
    • Console
    • Coach
    • Disciplinary Action
  • Human Factors assessment:
    • Identify human errors and the category of the errors: Knowledge-, Rule-, or Skill-Based
    • Identify Active and Latent Failure Factors contributing to errors identified
    • Provide relevant, logical root cause analysis (RCA) for identified factors
  • Provide specific improvement recommendations to address root cause(s) of failures
    • Use the human factors questions for analyzing systems as presented in Human Factors Analysis in Patient Safety Systems.
    • Use any other improvement models or methods reviewed in class (e.g. 7 Wastes, Value Stream, Flow, Standard Work, etc.)
    • Hint: You need to go beyond recommendations for training/communication
    • Consider potential barriers

The proposal should be 6-7 pages, focusing on quality improvement, patient safety and/or performance improvement integration. The paper should be written in a concise and academic manner citing relevant resources to support your arguments, using APA writing style guidelines include in text citation