Go to The Joint Commission Website and read the 2017 National Patient Safety Goal and view the 2017 National Patient Safety Goal Presentation
Watch Video – Select TST for Hands off Communication Webinar located in your module under multimedia.
Read the Case Study located in your module . In answering the questions, please write in paragraph style using APA format for this formal paper.
View the sample paper provided to help guide you. Select your own topic for this assignment ( ex: bar codes) and answer the questions listed and support with 1-3 professional journals to support your thoughts. The rubric will also be a guide to be sure to includes all required components. You are answering the question as it pertains to Ms Kain at the end of the case study (What can be done to keep it from happening again)? Brief evidence should be included to support your thoughts. Please also review grading rubric to be sure all components are within your submission.
Use the grading rubric to assess your paper prior to submission.
Submit this assignment under the “assignments tab” at the top of the page
No discussion board due in week 2.
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Red: >= 80 and <= 100% (You will earn a zero on your paper, yes you can re-submit before the deadline)
Do not plagiarize, which is stating verbatim from your reading and not giving someone credit by using at the end of the citation (Author, Year).
The National Patient Safety Goals (NPSGs) have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness. Recent changes have focused on preventing hospital-acquired infections and medication errors, in addition to existing goals promoting surgical safety, correct patient identification, communication between staff, and identifying patients at risk for suicide. In 2014, the group added improving the safety of hospital alarm systems, with a plan for a phased implementation of performance measures. For 2017, there are no new NPSGs, but new requirements related to establishing policies and procedures for managing alarms and educating staff about alarm systems will go into effect starting January 1, 2016. A recently added Patient Safety Primer discusses alert fatigue.
Please visit 2017 National Patient Safety Goals Presentation As nursing professionals, we must all be familiar and adapt the safety goals in our nursing practice. The National Patient Safety Goals, will enhance your knowledge and further review the NPSG.
Citation: The Joint Commission. (2017). National patient safety goals effective January 6, 2017. Retrieved from Citation: The
Applying National Patient Safety Goals
What can be done to keep the scenario below from happening again?
Please just submit a title page, answer these questions summarizing in paragraph form (not question 1,2,3), and then a reference page for grading, do not include the entire case study.
Title Page HYPERLINK “http://owl.english.purdue.edu/owl/resource/560/01/” Sample Title Page in APA format
Analyze the communication of the interdisciplinary team. Example -create a culture of safety (such as, open communication strategies and organizational error reporting systems)
Address critical thinking and what could be done to prevent future miscommunication from re-occurring.
Recommend changes where critical thinking was lacking and strategies to prevent this from occurring.
Evaluate the use of nursing informatics for improvement in patient outcomes in the case study.
How will making the changes you recommend promote quality safe and cost effective patient care to improve patient outcomes?
Reference Page HYPERLINK “http://owl.english.purdue.edu/owl/resource/560/10/” Sample Reference Page in APA format
Ms. Kain, a 75-year-old retired teacher, made a rare visit to her primary physician, Dr. Summer, who was affiliated with Curative Health. Melissa saw Dr. Summer that day to discuss persistent heartburn, which had progressively worsened despite taking Prilosec OTC for the last month. Dr. Summer examined Ms. Kain, discussed her symptoms and decided she needed an esophageal motility study and a 24-hour esophageal pH study to be performed in the Curative Health GI lab. Dr. Summer wrote an order for the tests, completed the appropriate forms and signed his name.
On that same day, Ms. Kainer, a 52-year-old bus driver, was seen at the Internal Medicine clinic at Curative Health for her yearly physical with Dr. Kim. She reported some arthritis problems in her right knee and a little “stomach trouble” after eating Mexican food. Dr. Kim ordered routine blood work and asked Mary to schedule her annual mammogram at her convenience. Mary thanked Dr. Kim and left.
Late that afternoon, Dr .Summer’s nurse called Curative Health’s centralized scheduling service to schedule Ms. Kain’s tests. Here’s how the call went:
Nurse: “Hello. This is Jane from Dr. Summer’s office. I need to schedule an esophageal motility study and a 24-hour esophageal pH study for Melissa Kain.”
Scheduler: “Okay. Let me pull that up on the computer. Now make sure I have those tests right … an esophageal motility study and a 24-hour esophageal pH study. Right?”
Nurse: “Yes, that’s right for Miss Kain, Dr. Summer’s patient.”
Scheduler: “We’ve got a slot at 2:30 on January 5. I’ve got that scheduled. Thanks.” The call ended.
While she was on the phone, Curative’s centralized scheduler was looking at the online scheduling system called IDX. After working 20 years in admissions, she had just transferred to the centralized scheduling center, but was well experienced with scheduling patients into IDX. When the scheduler heard the patient’s name, she entered the last name into the computer and found the patient. She completed making the appointment and filled out a form called the Diagnostic Center Patient Information that would be sent to the GI clinic. This “pink sheet” contains patient demographics, primary physician name, referring physician name, insurance information, and exam information. She then faxed the sheet to the GI lab, scheduling the GI tests on January 5 for Ms. Kainer. In order to prepare the patients for their procedures, the GI nurses call all patients the day before the procedure to give instructions about any preparation they need and to remind patients of their appointment times. On January 4, a GI nurse called Ms. Kainer’s house to speak with her about her GI tests that would be performed the following day. Mary was on her afternoon bus route, so she did not receive the call. The GI nurse left the following message on Mary’s answering machine:
“Your primary care physician has scheduled you to have an esophageal motility study and a 24-hour esophageal pH study at 2:30 p.m. tomorrow with Dr. Magee at the GI lab. Please arrive at the lab 15 minutes early and bring your insurance card. The GI lab is located in the Physicians Office Park on Rangeline. Thank you.”
Although Mary wasn’t expecting the call and knew nothing about a GI appointment, she assumed that Dr. Kim wanted a specialist to check on her stomach troubles so she arrived promptly at the GI clinic at 2:30 p.m. on January 5. She checked in with the receptionist who “arrived” Mary at the clinic into the IDX system. The receptionist pulled Mary’s pink sheet, notified the nurses that she was here and asked Mary to have a seat in the waiting room.
The GI lab was running on time that day; the nurse called out “Ms. Kainer,” and she was quickly taken back to the procedure room. The GI lab does not routinely gain informed consent for a motility study because the risks from the procedure are very low; most patients just experience some minor discomfort. The GI nurse slipped an esophageal pressure tube through Mary’s nose into her esophagus and was just completing the test as Dr. Magee entered the room. When he mentioned that he would be sending results of this test to Dr. Summer, she responded, “I’m not sure what doctor you’re talking about. My family doctor is Dr. Kim.”
At that point, Dr. Magee asked to see the original order from Dr. Summer’s office. Sure enough, the order from Dr. Summer was for Ms. Kain. Dr. Magee immediately informed Mary of the mistake, apologized and told her his office would get to the bottom of the incident and make sure it didn’t happen again. Mary was not upset and asked Dr. Magee about her “stomach troubles.” Dr. Magee told Mary her esophageal motility study was completely normal. The second test was not performed, and Mary was not charged for the first study.
Case Contributing Factors:
Equipment (design, availability and maintenance)
There were no alerts built into IDX computer system for duplicative or sound alike names or no forcing function to verify all demographic information before scheduling.
Environment (staffing levels and skills, workload and shift patterns, administrative and managerial support, physical plant)
Were there too many calls or scheduling tasks at once?
Teamwork (verbal and written communication, supervision and assistance)
Was communication between front line team members (scheduler and nurse) adequate?
Staff (knowledge and skills/training, competence, physical and mental health)
Team may blame the scheduler for not picking the right patient (misunderstanding sound alike names and not verifying the correct patient). Reasons: Humans are fallible and errors are to be expected. “Leaving out necessary task steps is the single most common human error type.” How many times have you left the last page of your original in the photo copier?
Scheduler performed task at least 50 times a day … wasn’t lack of experience or training. Sometimes humans omit necessary steps from common tasks.
Reason’s work on approaches to human error – viewed either as person approach or system approach. In person approach, errors are the fault of a human who should have acted differently (labeled careless, poorly motivated, negligent, forgetful). In a systems approach, errors are seen as consequences of upstream system factors including recurrent “error traps” in workplace.
Institutional Context (economic and regulatory situation, availability and use of protocols, availability and accuracy of tests)
Were there methods for monitoring adequacy of staff communication in place at this institution?
Organization/Management (financial resources and constraints, organizational structure, policy standards and goals, safety culture and priorities)
1. GI nurse leaving message on answering machine.
Might blame the nurse for not directly speaking to patient instead of leaving a message.
Was it a workplace norm for GI lab to leave messages on machines? Also, it was procedure to call the day before necessitating leaving the message on machine, not waiting for patient to call back.
2. Process for scheduling patients did not include scheduling test from ORIGINAL order and also did not include a comparison of written ORIGINAL order with “pink sheet” sent from schedulers.
3. Process of clinic verification of patient included only patient agreement with demographic information. In this case didn’t catch wrong patient. Needed referring physician name. Standardized approach was missing. Left to individual receptionist, nurse, etc. to determine how to verify patient. Most used name only.
4. Process for consenting the patient. Verifying basic information BEFORE test performed.
May blame the patient. Why didn’t patient question the unknown test? Trust of health care system and personal physician. Patient get comfortable with physician’s not communicating what the treatment plans are. Cultural norm. Age differences.
Application of National Patient Safety Goals
Columbus State University
NURS 3191 Professional Clinical Nursing RN I
Application of National Patient Safety Goals
Every day in the healthcare profession, patients are at risk for being the victim of an unintentional error. As we know, humans are not perfect and unfortunately are susceptible to making errors. However, this is not an excuse and should never be. Once a nurse begins his or her shift, they are responsible for each life they come into contact. The life under their care can be a daughter, brother, husband, wife, mother, or father. Errors in the healthcare field happen every day, but we should not become numb to this fact. To prevent miscommunication errors in the future, solutions and changes include, the use of two patient identifiers by the National Patient Safety Goals, using the acronym STAR, and improvement in nursing informatics. The recommended solutions will improve overall patient care and outcomes while being cost effective.
According to the application of the 2017 National Patient Safety Goals case study, communication between the interdisciplinary team can be improved in many areas. Make sure to read the grading rubric and address each section in the body.
In conclusion, the importance of being educated on ways to prevent errors in the healthcare system is not a widely discussed topic. Now discuss your main points you mentioned in the introduction.
Househ, M., Ahmad, A., Alshaikh, A., & Alsuweed, F. (2013). Patient safety perspectives: The impact of CPOE on nursing workflow. Studies In Health Technology And Informatics, 183, 367-371. http://dx.doi.org/doi:10.3233/978-1-61499-203-5-367
Mazza, F. (2012). STAR: Preventing skill based errors. Retrieved from https://doctors.seton.net/stories/story-detail/star-preventing-skill-based-errors
The Joint Commission. (2016). https://www.jointcommission.org/hap_2017_npsgs/
National Patient Safety Goal Rubric (ADA)
Criteria Level 5
10 points Level 4
8 points Level 3
7 points Level 2
5 points Level 1
Criterion 1: Structural Integrity 10 points
Introduction clearly communicates topic
Ideas progress logically
Closing supports main idea 8 points
•Introduction communicates topic, Ideas in sequence, but don’t always progress
•Closing relates to main idea 7 points
Introduction fails to communicate topic, Ideas not in orderly sequence, Relationship between closing and main idea unclear 5 points
Poorly developed introduction No sequence, Relationship between closing and main idea not present 0 points
Criterion 2: Reasoning and focus consistency 10 points
Maintains focus on topic throughout
•Develops appropriate, logical, and relevant supporting detail and/or evidence
•Explains how, why, and in what way main evidence supports point 8 points
Appropriate focus on topic, but some deviation, Supporting detail and/or evidence is largely persuasive, Relationship between evidence and main point is largely explained
Insufficient focus on topic
Inappropriate, illogical, irrelevant, or missing, detail and/or evidence
Fails to connect evidence to main point
Poorly developed focus on topic
Missing, detail and/or evidence
Fails to connect evidence to main point
Language and audience appropriateness 10 points
Demonstrates the voice of a professional nurse
Presents awareness that audience will interpret ideas offered
Employs word choice appropriate for professional nurse 8 points
Voice mostly reflects a professional nurse, but with some gaps
Lacks appropriate awareness that audience will interpret ideas offered
Word choice is largely appropriate for a professional nurse 7 points
Voice lacks professionalism in whole or part
Lacks awareness of professional and thinking audience
Word choice inappropriate for a professional nurse
Consistently poor word choices for a professional nurse
APA 10 points
Correct APA document format (title page, running head, headings, etc.)
•All APA In-text citations have correct author name’s) and source date
•Paraphrasing and/or quotations accurate
•List of references titled appropriately and references in correct format
APA document format (title page, running head, headings, etc.) largely correct
•Most APA In-text citations have correct author name’s) and source date
•Paraphrasing and/or quotations have few errors
•List of references formatted so that readers could find information cited therein 7 points
•APA document format (title page, running head, headings, etc.) is flawed
•Errors in APA in-text citations, including incorrect author name’s) and/or source date
•Paraphrasing and/or quotations have errors
•List of references format problems could prevent or delay readers from finding information cited therein 5 points
Poor APA throughout paper
Grammar and mechanics support clear understanding of writer’s message, with few errors. Length of body of paper 4-5 pages. 8 points
Grammar and mechanics rarely impede writer’s message, with some errors present. Does not adhere to prescribed length of paper
Grammar and mechanics impede writer’s message, with too many errors present. Does not adhere to prescribed length of paper.
Poor grammar and mechanics throughout paper
Introduction clearly relevant to the NPSG case study 8 points
Introduction somewhat relevant
Introduction somewhat relevant but on one sentence 5 points
Introduction is not addressed
Interdisciplinary team is analyzed fully 8 points
Interdisciplinary team is analyzed partially 7 points
Interdisciplinary team is briefly analyzed
Interdisciplinary team is not analyzed 0 points
Critical Thinking 10 points
Fully addresses critical thinking and what could be done to prevent future miscommunication from re-occurring 8 points
Partially addresses critical thinking and what could be done to prevent future miscommunication from re-occurring 7 points
Briefly addresses critical thinking and what could be done to prevent future miscommunication from re-occurring 5 points
Does not address critical thinking and what could be done to prevent future miscommunication from re-occurring 0 points
Fully recommends sound solutions/changes/strategies where critical thinking was lacking in the case study for better patient outcomes
Fully identifies how making the changes/solutions identified will improve patient outcomes.
Partially recommends sound solutions/changes/strategies where critical thinking was lacking in the case study for better patient outcomes
Partially identifies how making the changes/solutions/strategies identified will improve patient outcomes. 7 points
Briefly recommends sound solutions/changes/strategies where critical thinking was lacking in the case study for better patient outcomes 5 points
Does not recommend sound solutions/changes/strategies where critical thinking was lacking in the case study for better patient outcomes
Promote improved patient outcomes 10 points
Conclusion/summary for the case study (summarize your points made in your introduction and does not add new material in the conclusion) 8 points
Partial conclusion/summary for the case study (summarize your points made in your introduction and does not add new material in the conclusion)
Only one point briefly identified to improve patient outcomes.
Does not make a conclusion/summary for the case study.
Does not identify how making the changes/solutions identified will improve patient outcomes.
Does not make a conclusion/summary for the case study.
Overall Score Level 5
100 or more Level 4
80 or more
Faculty reserve the right to award partial points for performance that does not fully meet the criteria Level 3
70 or more
Faculty reserve the right to award partial points for performance that does not fully meet the criteria Level 2
50 or more
Faculty reserve the right to award partial points for performance that does not fully meet the criteria Level 1