Addressing a Patient Safety Issue

Addressing a Patient Safety Issue

Patient safety needs a high level of care at work as well as patient care from the time they enter the institution until they depart. Patient safety is described as the absence of avoidable patient harm when obtaining healthcare services, hence minimizing the chance of unintended damage. It is critical to remember that healthcare is unpredictable at all levels, emphasizing the need for laws, business structures, ethical standards, and regulators to protect patients. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was designed to protect patient confidentiality in healthcare, to improve healthcare, to eliminate waste, and to encourage workers to seek medical treatment via their employers (World Health Organization, 2021). This has evolved significantly over time, with a greater emphasis on patient confidentiality and specific measures such as infringement notice laws, privacy rules, safety regulations, and omnibus regulations becoming more popular. In the case of a HIPAA breach, all stakeholders must be engaged in discovering the root cause and taking action to protect patients, health professionals, and health facilities in the future, as required by regulations.

Potential Threat to Patient Safety

Healthcare delivery is governed by laws, conventions, and ethical norms, which assure patient safety while also improving caregivers’ working circumstances. Health systems must undertake interventions and evaluations in order to address difficulties related to their goals and objectives, as well as the fact that such needs and recommendations exist. When the Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements are violated, it poses a security risk (Melderet al., 2020). During a conversation between two employees, others close by demonstrated a lack of accountability, which may have led to betrayal or distrust. The father of B. Moore overheard Ida and Brenda, a nurse from another ward, discussing patients at the front desk, which was against hospital policy. The first tale concerns ward employees interacting with patients; the second concerns the ward secretary who handles the patient; and the third concerns the patient. The department secretary has an encounter when dealing with another department employee, which serves as the foundation for the following story. Every day, medical experts make rounds at the Independence Medical Center children’s ward to ensure that all of the children get adequate care. During the round, she saw two patients with the same name and date of birth and called the patient’s nurse with the same name to find out what was going on.

According to Virginia Anderson, a patient care worker, the two patients had almost similar numeric birth dates, first and last names, and middle initials. For example, B. Moore was born on 8/11/05, whereas B.R. Moore was born on 11/8/05; the only difference is the middle initial. Kira then asks what the nurse did to avoid a possible disaster between the two patients. Virginia made certain that each patient’s medical record had information such as identical names, digital birth dates, and the fact that each patient was cared for by a different nurse. Moore received medical treatment accidentally on August 11, 2005, despite verbal assurances that all processes were followed. This resulted in a taped conversation between two medical facility front-desk workers. Failure of healthcare organizations and hospital personnel to adequately manage patient confidentiality risks may result in the dissemination of inaccurate information, disputes among colleagues, patients losing trust in doctors, and a negative public image for the institution.

Imperative Health Care Protection Criteria

Health care safety is concerned with the critical role that health care responsibilities play in, among other things, determining outcomes based on patient engagement in treatment, maintaining a healthy population, and minimizing per capita healthcare expenses. The Institute for Health Improvement (IHI) will be able to achieve the health initiative’s three goals, which include addressing health challenges at all levels of government, the general public, communities, and health professionals (Melder et al., 2020) Six goals have been established by the Agency for Health Research and Quality to maintain consistency in health and healthcare delivery (AHRQ). Patients will benefit from fewer prescription errors, more patient and family engagement in healthcare decision-making, and lobbying for improved care coordination and treatment continuity both within and outside the hospital. Let us talk about it. These health care protection guidelines ensure that all stakeholders are involved in proposing solutions and limit extra harm to patients and families in the event of a HIPAA violation by conversing with patients who are within hearing distance of parents. HIPAA Infractions (Wong et al., 2020).

The PSO (Patient Safety Officer), the hospital ethics committee, Ms. B. Moore, the nurse, and the ward staff must design the best approach for addressing as few medical errors as possible in this situation. Imperative health care contains detailed instructions on how to resolve issues and the processes that must be followed to protect the dignity of inpatients. Following prescription errors and unintended maternal exposure, hospital boards, for example, were confident in B. Moore’s safety because they implemented the necessary precautions and recognized the first three objectives of the National Quality Strategy, which were met following pharmaceutical errors. Involving Moore’s mother in the system-adjustment process boosts trust in the healthcare system while increasing communication channels ensures that all points of view are given, questioned, and examined with an open mind (Park & Giap, 2020).

The Joint Committee and the Hospital Ethics Committee are the two key regulatory bodies in charge of overseeing the situation’s progression. These groups may be useful in striking a balance between patient care and government oversight. The Joint Commission has set its own patient-care goals that are in line with the national quality policy (Abduh et al., 2020). In the current atmosphere, attaining the first three aims of the Joint International Commission is crucial. These goals include improved patient assessment, coordination, and medication management. These organizations ensure that patient care is consistent by establishing recommendations or standards for treating patients who are at risk of unfavorable consequences. Those who violate these regulations face administrative fines, potential litigation, and financial penalties.

The Role of Patient Safety Officer

The Patient Safety Officer (PSO) is responsible for developing, supervising, and maintaining all types of interactions required for the healthcare system to function correctly (Bernardes et al., 2021). The PSO must also develop criteria and techniques for detecting potential hazards, rating success, and finding cultural gaps in the organization’s operations. According to the organization, the goal of PSO is to increase openness across all health units and institutions by regularly involving nurses and other healthcare discipline teams. As a consequence, the execution of these tasks and responsibilities will contribute to the long-term effectiveness of patient protection initiatives. Consider putting in place a clear and consistent communication framework to help PSOs better grasp the obstacles that health care providers face when dealing with these concerns (Ridelberg et al., 2020). In contrast, a transparent engagement platform increases PSOs’ appreciation and value of their connections with healthcare providers and other stakeholders.

PSOs should be seen as a resource for connecting, reporting, and collaborating rather than being watched. It was my obligation as PSO to call the pediatric ward’s nurse and push dialogue after confirming the unit’s breakdown. My primary role will be to act as a bridge between the pediatric ward nurses and the hospital ethics team. When conversing with the patient’s mother, she provided all relevant facts about her circumstances without bias or evidence manipulation. It is necessary to approach these challenges in stages and with a strategy (Abduh et al., 2020). To provide acceptable answers to patient safety concerns, healthcare practitioners are given a framework and educated to recognize appropriate situations and forecast consequences. A plan describes the goals of the healthcare system and ensures that trustworthy procedures and learning opportunities are accessible along the way (Abduh et al., 2020). The PSO system devises methods for precisely assessing resources and distributing plans. Internal planning and employee awareness will augment the current patient safety support system, as well as the patient safety strategy and structure. Having all three ensures that discoveries are made fast and that the dangers of making mistakes are reduced without jeopardizing the healthcare system as a whole.

Recommendations to Reduce Patient Safety Threat

Assessment And Improvement of The Security Community

A detailed study of the practice, ideology, and historical development of today’s healthcare organizations may help identify systemic issues in the field. As a consequence, it is critical at each level to assess the stages and processes of health care and propose new solutions when existing ones become insufficient and ineffective.

Effective Coordination and Teamwork

Healthcare may increase if current systems collaborate to maintain a healthy balance between them. To facilitate networking, regulations, and processes encouraging collaboration and employee relationships must be developed. A quick talk with the nurses and doctors on the ward before the rounds to encourage one another to have a good day and to always strive for success is likely to increase the group’s cohesion and relationships over time. Meanwhile, a daily behavioral analysis is likely to help spot concerns, important events, and changes throughout the week and during the transition, as well as provide early treatment to minimize patient harm.

Ensuring Long-Term Viability and Continuity

Patient safety should be emphasized at all levels of professional involvement. These technologies include but are not limited to, those that help with injury monitoring, opening inpatient rooms, and reducing human error in the medical field. By expanding the number of people who utilize health services, systematic reporting of results may serve to improve transparency and continuity in health care.

Increase Patient and Family Involvement

Patient participation warns nurses and doctors that they may be ignored, which is especially important when medical data is scarce. By fostering a safe environment, this phase fosters mutual confidence between patients and healthcare personnel. Patient participation, regardless of age, race, religion, or socioeconomic background, usually results in a positive atmosphere of permission that takes the patient’s perspective into account. If the patient is under the age of 18 or is unable to speak properly with the doctor, family members have the right to voice their ideas and make recommendations. As a result, the overall quality of medical therapy offered may improve.

Technology Integration

Because of technology improvements, the process of individuals acquiring and exchanging data has been simplified. To improve service quality, a system that employs technology to collect patient data, update medical records, and monitor prescriptions must be built. Information is now available from everywhere thanks to technological improvements. This should enable doctors to conduct testing and training courses while still adhering to regulatory standards, so increasing the quality of their work for the benefit of patients.


Abduh Saaid, B., Abdullah, S. M., & Abo Elmagd, N. S. (2020). Effect of Applying A training Program about International Patient Safety Goals on Patient’s Safety Culture. Assiut Scientific Nursing Journal8(22), 133-144.

Bernardes, A., Gabriel, C. S., & Spiri, W. C. (2021). Relevance of leadership regarding patient safety in the current context. Revista Latino-Americana de Enfermagem29.

Melder, A., Robinson, T., McLoughlin, I., Iedema, R., & Teede, H. (2020). An overview of healthcare improvement: unpacking the complexity for clinicians and managers in a learning health system. Internal medicine journal50(10), 1174-1184.

Park, M., & Giap, T. T. T. (2020). Patient and family engagement as a potential approach for improving patient safety: a systematic review. Journal of advanced nursing76(1), 62-80.

Ridelberg, M., Roback, K., & Nilsen, P. (2020). How can safer care be achieved? Patient safety officers’ perceptions of factors influencing patient safety in Sweden. Journal of patient safety16(2), 155-161.

Wong, B. M., Baum, K. D., Headrick, L. A., Holmboe, E. S., Moss, F., Ogrinc, G., … & Frank, J. R. (2020). Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care. Academic Medicine95(1), 59-68.

World Health Organization. (2021). Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care.


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