...immense dedication and support in improving patient safety in recent years. Without their invaluable and incessant efforts in planning and executing various improvement initiatives to enhance patient safety through risk identification and mitigation, the publication of this annual report would not have been as meaningful. Patient Safety and Risk Management Department Quality and Safety Division 2 ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) TABLE OF CONTENTS Executive Summary 4 CHAPTER 1 – Introduction 9 CHAPTER 2 – Sentinel and Serious Untoward Event Policy 11 CHAPTER 3 – Sentinel Events Reported from 1 October 2012 to 30 September 2013 13 CHAPTER 4 – Serious Untoward Events Reported from 1 October 2012 to 30 September 2013 21 CHAPTER 5 – Actions Taken and Discussion 26 CHAPTER 6 – Conclusion 42 CHAPTER 7 – The Way Forward 44 Annex I: Annex II: HA Sentinel and Serious Untoward Event Policy Summary of Individual Sentinel Events and Recommendations for Improvement 3 ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October...
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...A study entitled, “A Controlled Trial of Smart Infusion Pumps to Improve Medication Safety in Critically Ill Patients” was completed (Rothschild et al., 2005). The authors’ purpose was to “assess the impact of smart pumps with integrated decision support software on the incidence and nature of medication errors and adverse drug events” (Rothschild et al., 2005). The study was conducted in 2002 at a large tertiary care medical center in Boston, Massachusetts. More specifically, the study focused on patients who had been admitted to two cardiac intensive care units and two cardiac step-down units. Many medical centers are transitioning to use of smart pumps, in hopes of reducing medication errors and adverse drug events. Summary The goal...
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...PPACA will, or is supposed to, eliminate lifetime and unreasonable annual limits on healthcare benefits; prohibit health insurance policy recessions; extend dependent healthcare coverage up until the age of 26; provide assistance to uninsured due to pre-existing conditions; cap insurance administrative expenditures; require coverage for immunizations and preventative services; develop uniform coverage documents allowing consumers to juxtapose different insurance plans from different insurance providers; create temporary re-insurance programs to support coverage for early retirees; simplify healthcare administration as a means to lower health system costs; create an internet portal for consumers to identify insurance coverage options; and implement an appeals process to guarantee consumers and provide consumers assistance processing and accessing their insurance coverage ("PPACA Summary," n.d.) The PPACA does expand public programs, e.g. expanding the eligibility for Medicaid to lower income people; simplify Medicaid and enhance the Children’s Health Insurance Program; simplify enrollment; and expand resources to community based programs, just to name a few. The PPACA will affect every community in the United States, changing the way businesses provide healthcare, holding hospitals and other healthcare facilities more accountable, and providing individuals with more options vis-à-vis insurance options. The PPACA is paradoxical; it will, according to the data, ensure Americans quality...
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...Implementation Guide for the Use of Bar Code Technology in Healthcare Sponsored by Implementation Guide for the Use of Bar Code Technology in Healthcare © 2003 HIMSS 230 E. Ohio St., Suite 500 Chicago, IL 60611 All rights reserved. No part of this publication may be reproduced, adapted, translated, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. HIBCC ® and HIN® System are trademarks of the Health Industry Business Communications Council. ISBN: 0-9725371-2-0 Table of Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi Chapter 1: The Basics What is a bar code? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 How can you benefit from bar coding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
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...may include misuse of service which is generally preceded at onset by prior unacceptable level of errors. The purpose of this paper is to highlight medication errors as a health care safety issue. One solution involving automation would be explored since it has long been recognized as an important factor in reducing human errors in work processes. It is crucial to showcase this because numerous studies have substantiated the positive effects of health IT on quality and safety improvements, Slovenky & Menachemi (2011). A safety Initiative With new tools provided by the Affordable Care Act, hospitals can now aggressively implement programs with sole aim of assisting in the reduction of preventable errors. The act provides hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals, to support their efforts to reduce harm, McKinney & Zigmond (2011). The government predicted that this could save 60,000 lives over the next three years and potentially save up to $50 billion in Medicare bill. The federal government is encouraging providers to adopt and effectively use electronic health record (EHR) systems, Heubusch (2011). The goal in the development and use of EHR’s is to enable effective and measurable improvements in the health of individuals and fully involve them in the process....
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...You Decide Week 6 Little Falls Hospital Risk Management HSM 542 Health Rights and Responsibilities Purpose A risk management plan is created so as to support Little Falls Hospitals mission and vision statements as it pertains to the clinical risk of the hospital, patients, visitors, volunteers, and employee safety, and any possible operational, business, and property risks. Culture Principles The Patient Safety and Risk Management program will support Little Falls Hospitals philosophy; everyone is responsible for patient safety and risk management. It is essential to have participation and teamwork among providers, management, staff and volunteers. The Patient Safety and Risk Management program will be implemented with the coordination of multiple organizational and department functions and activities. Little Falls Hospital will support the introduction of a just culture with emphasis on evidence based best practices, learning from errors, and providing feedback instead of punishment and blame. In a just culture any unsafe conditions or hazards will be identified quickly, medical or patient care errors will be reported and analysed, open discussions of mistakes and suggestions for improvements are welcome with patient safety and risk management practices. Individuals will still be held accountable for compliance. When evaluation and investigation into errors reveals there has been reckless behaviour or there has been wilful violation of policies then disciplinary...
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...Nightingale Executive Summary Western Governor’s University Nightingale Executive Summary Nightingale Community Hospital is a 180 bed hospital that provides acute care and a range of services to their community. Nightingale has four core values that consist of safety, community, teamwork, and accountability. Communication is a key concept in achieving and defining those values. According to the National Patient Safety Goal Data in regards to communication for Nightingale Community Hospital there is not consistency and goals are not being met for the following: reporting critical results within 60 minutes as evidenced by documentation, verbal orders/read-backs, unacceptable abbreviations, and time out hospital wide. Critical Results Within 60 Minutes Nightingale Hospital has showed variations in compliance with reporting critical results within 60 minutes for the months of January through December. Compliance went from 63% in January to 80% in December. In between this time there have been significant variances. As noted there from the data there was only 56% and 57% compliance for the months of June and July. Reporting of Critical Results with 60 minutes should be at 100% compliance. Verbal Orders/Read-Backs The ED met 100% compliance with verbal order/read-back audits for the fiscal year to date. Ortho is at 62% compliance. The other departments at Nightingale Hospital are ranging from 91% to 99%. For JCAHO standards the departments should be at 100%. ...
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...Nursing and Midwifery Council (NMC) is the UK regulator for two professions: nursing and midwifery. The primary purpose of the NMC is protection of the public. It does this through maintaining a register of all nurses, midwives and specialist community public health nurses eligible to practise within the UK and by setting standards for their education, training and conduct. One of the most important ways of serving the public interest is through providing advice and guidance to registrants on professional issues. The purpose of this booklet is to set standards for safe practice in the management and administration of medicines by registered nurses, midwives and specialist community public health nurses. Standards for medicine management replace the Guidelines for the administration of medicines 2004, although many of its principles remain relevant today, for example: “The administration of medicines is an important aspect of the professional practice of persons whose names are on the Council’s register. It is not solely a mechanistic task to be performed in strict compliance with the...
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...http://www.nap.edu/catalog/9728.html We ship printed books within 1 business day; personal PDFs are available immediately. To Err Is Human: Building a Safer Health System Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine ISBN: 0-309-51563-7, 312 pages, 6 x 9, (2000) This PDF is available from the National Academies Press at: http://www.nap.edu/catalog/9728.html Visit the National Academies Press online, the authoritative source for all books from the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine, and the National Research Council: • Download hundreds of free books in PDF • Read thousands of books online for free • Explore our innovative research tools – try the “Research Dashboard” now! • Sign up to be notified when new books are published • Purchase printed books and selected PDF files Thank you for downloading this PDF. If you have comments, questions or just want more information about the books published by the National Academies Press, you may contact our customer service department tollfree at 888-624-8373, visit us online, or send an email to feedback@nap.edu. This book plus thousands more are available at http://www.nap.edu. Copyright © National Academy of Sciences. All rights reserved. Unless otherwise indicated, all materials in this PDF File are copyrighted by the National Academy of Sciences. Distribution, posting, or copying...
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...Health Care Mitchel Breedlove HCS/449 September 3, 2015 Dr. Janice Chilton Health Care In this paper I will discuss what I already know about technology in health care, and how I think this technology will change health care as well as summarize the article used to determine each. What do I already know about technology in the health care? I know that technology is one of the fastest growing and leading within the health care industry. There have been several innovate ways that we were able to discover different methods to prevent diseases as well as ways to cure individuals. Technology has come so far since the early times and we now have types of x-ray machines, EKG readings, heart monitors, imaging of the body, blood pressure machines and so many other new advances in technology. We can know determine the oxygen concentration in blood, study the brain waves, understand the breathing rates and for the most part determine what makes each individual tick. Technology can now image parts of the body showing different signs and symptoms that can help doctor’s diagnosis early stages of diseases in patients. Remarkable technology has truly come along way. Even today scientists and doctors are still working together to help each other understand how we can be for more advanced in understanding the complexity of the human body. I am fascinated on how technology has improved over the course of years. In the mid 90’s the outbreak of HIV was very serious and many physicians...
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...Caring Hospice Business Plan Bonita Lewis Central Methodist University COMPANY SUMMARY/CATCHY-SELLS Caring Hospice is a new hospice company in its start-up stages. It will offer compassionate and caring end of life care for terminally ill patients and their families in southeast Missouri. The company name “Caring Hospice” is catchy and easily remembered by consumers. The name indicates that this company will care for dying loved ones. MARKET ANALYSIS Caring Hospice will be located in Poplar Bluff, Missouri. This is the southeastern region of the state. It is comprised of poor communities where residents often are forced to travel as far as fifty miles or more for adequate health care. Market research shows there is a significant need for quality hospice care in this region, with only six competitors that travel to the homes of patients living in the rural counties (Yellow Pages, n.d). Caring Hospice will thrive for years to come simply due to the fact that it will bring care to the patients in their own homes. FINANCIALS The start-up budget includes a list of expenditures (Henderson, 2003). The expenses will be compiled of operating and non-operating costs (Dunham-Taylor & Pinczuk, 2010). The start-up costs will be paid with a new business loan the first 90 days. After this time, the business will be able to support itself with revenue from billing to Medicare, Medicaid, and private insurances (Hogan & Hartson, 2012). The estimated beginning...
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...Executive summary The paper is all about Bureaucracy and how it can be effective as the systematic way to change and innovation in an organization. In the paper we will focus on an organization such as a hospital where gives patients health services and treatment. Such an organization needs a systematic way of running it or else it will be bankrupt and lead to shut down hence there should be a form of governance in the organization that should be into place and should be followed because such an organization is very critical because it carries out the task of saving lives. The report will try and show how bureaucracy is the best method to run in such a firm. The report also will try and show what bureaucracy is all about and how it affects the firm in terms of the employers and the employees and also the running itself. The report shows the leadership aspects that are used in a bureaucratic manner and how they have brought change in the firm and also what innovations have been noted in the system. Globally, healthcare services are complex in terms of affordability and other challenges and the bureaucratic mode of governance simplifies the whole system and these aspects are carried out in the report. Introduction Bureaucracy is a system or a mode of administration marked by specialization of best function and adherence or following of rules and also in follow up of a hierarchy. Health care systems are complicated entities that must have the best administrative roles and also good...
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...ADITYA KUMAR DASH BTM 2nd Stage Bangalore, Karnataka India – 560076 adi.k.dash@gmail.com +91‐9620936796 Summary of Skills Business Analyst with People Management Skills, Customer Relationship Management and expertise in Software project development and management in Agile methodology • Over 5 years of experience in gathering requirements for software application development projects • Eliciting requirements using interviews, document analysis, requirements workshops, site visits, product related descriptions, use cases, scenarios, business analysis, and task & workflow analysis. • Delivering IT Solutions involving requirement analysis and management, project scope definition, implementation and testing of applications built for Windows, Mobile devices and Web in internet/intranet infrastructure • Critically evaluate information gathered from multiple sources, reconcile conflicts, decompose high-level information into details, abstract up from low-level information to a general understanding, and distinguish user needs from the required system • Proficient in documenting business requirements in Agile methodology, creating Functional specifications, User Interface design, Use Case Modeling, Process flows and reviewing Test Case document • Expertise in Software Development Lifecycle (SDLC) management and Business to Business (B2B) integration concepts • Proficient at Scrum model & processes and Agile methodologies...
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...Harrison-James Keller Graduate School of Management December 11, 2011 Table of Contents EXECUTIVE SUMMARY………………………………………………………………………………………………………3-4 DEFINE THE PROBLEM/ISSUE……………………………………………………………………………………………..5 IMPROVING QUALITY OF HEALTH……………………………………………………………………………5 IMPACT ON HEALTH CARE COST………………………………………………………………………………5 IMPACT ON HEALTH CARE DELIVERY SYSTEM………………………………………………………….5 LITERATURE REVIEW…………………………………………………………………………………………………………..6 WHAT IS HEALTH INFORMATION TECHNOLOGY……………………………………………………...6-8 INFORMATICS IN HEALTHCARE……………………………………………………………………………….8-9 BENEFITS OF INFORMATICS……………………………………………………………………………………9-10 PROBLEM ANALYSIS…………………………………………………………………………………………………………..10 THE COST OF HEALTH IT………………………………………………………………………………………10-11 HOW IT IMPROVED QUALITY………………………………………………………………………………….12 POSSIBLE SOLUTIONS…………………………………………………………………………………………………………12 (1). PERSONAL HEALTH RECORDS……………………………………………………………………………12 (2). E-PRESCRIBING…………………………………………………………………………………………………13 (3). COMPUTERIZED PROVIDER ORDER ENTRY……………………………………………………….13 SOLUTION AND IT IMPLEMENTATION……………………………………………………………………………14-15 JUSTIFICATION………………………………………………………………………………………………………………15-16 REFERENCES……………………………………………………………………………………………………………………..17 ------------------------------------------------- EXECUTIVE SUMMARY The use of technology in health care has become a huge topic in the medical world today....
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...become a necessity even in the health care system and is covered by the federal regulations. The implementation of the Electronic Health Records (EHR) by 2014 has become mandated as ordered by President George.W.Bush in 2004 which was seconded by the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) and Health Insurance Portability and Accountability Act (HIPAA). These organizations asked the health care providers to comply with the new legislation and those community-based physician practices who were earlier reluctant to accept and implement it have now realized that the health care in sequence systems in the form of CPOE (computerized physician order entry), EMR (electronic medical records), the tele-medicine, complex disease management, and automated billing systems are very beneficial to them The paper intends to showcase the comparison and contrast between a contemporary health care facility and a traditional health care facility which prevailed before twenty years. At least two major events and technological advantages influencing the practice of the current health care information system are also included in this paper. Definition of Health Care Information System It would be better to understand the two primary classes of health care information system; the Clinical and administrative information systems, prior to the discussion of its evolution and growth in the last two decades. To quote Wager, Lee, and Glaser (2009),” A health care information...
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