Perform an Internet search to identify and research and a situation where a health care organization or individual provider in your field of allied health was sanctioned by The Joint Commission or other regulatory body for a violation of one or more of The Joint Commission workplace safety, risk management, and quality care requirements.
Taking the role of the Chief Safety or Risk Management Officer in the organization or a provider’s office who now must deliver an accounting of the incident to the board of directors, develop a slide presentation, containing a title slide, 12-15 slides of content, and a references slide, focusing on the chosen incident. Your presentation must incorporate the following:
- A brief summary of the incident , including a description as well as the outcome.
- A summary of the applicable Joint Commission and other (e.g., local, state) regulatory standards that apply to the incident.
- A discussion of the mistakes and/or oversights made by the health care organization or individual provider that did or may have led to the incident that occurred, and an accounting of the preventive steps that could have or should have been taken to avoid them.
- A proposal outlining specific education or training the organization or provider will employ to ensure this type of incident does not occur in the future. Include concepts related to continuous quality improvement in your recommendations.
To create your presentation you can use PowerPoint or a program such as Prezi (www.prezi.com). Speaker’s notes must be included for each individual slide.
You are required to use and cite a minimum of three qualified resources
Expert Solution Preview
Introduction:
The incident that will be discussed in this presentation involves a health care organization that was sanctioned by The Joint Commission for a violation of workplace safety, risk management, and quality care requirements. As the Chief Safety or Risk Management Officer, it is essential to provide a comprehensive account of the incident to the board of directors. This presentation aims to summarize the incident, discuss the relevant regulatory standards, analyze the mistakes made, provide preventive steps, and propose specific education or training for future prevention.
1. Brief Summary of the Incident:
The incident involved a patient who suffered a serious medication error due to a breakdown in the medication administration process within the organization. The outcome was severe harm to the patient, leading to an extended hospital stay and additional medical interventions.
2. Applicable Joint Commission and Regulatory Standards:
The incident is a clear violation of The Joint Commission’s medication management standards, which focus on safe medication practices, prescribing guidelines, medication administration procedures, and staff education regarding medication safety. In addition to The Joint Commission, local and state regulatory standards related to medication safety and patient care were also violated.
3. Mistakes and Oversights Leading to the Incident:
Several mistakes and oversights contributed to the occurrence of this incident. Firstly, there was a lack of clear communication between the healthcare team members regarding the patient’s medication orders. Secondly, the documentation process was incomplete and inconsistent, leading to confusion among the staff. Additionally, the organization failed to implement a formal medication reconciliation process, resulting in incomplete information about the patient’s medication history. These mistakes could have been avoided through proper training, standardization of processes, and ensuring effective communication channels.
4. Preventive Steps to Avoid Future Incidents:
To ensure that such incidents do not occur in the future, the organization must implement specific education and training initiatives. These initiatives should focus on improving medication administration processes, enhancing communication and documentation practices, and reinforcing the importance of medication safety protocols. Continuous quality improvement concepts, such as conducting regular audits and performance reviews, should be integrated into the education and training programs. Additionally, the organization should establish a culture of safety, encouraging staff members to report near misses and potential errors to foster a proactive approach towards preventing incidents.
In conclusion, this presentation has provided a comprehensive overview of the incident involving a violation of workplace safety, risk management, and quality care requirements within a healthcare organization. It highlighted the mistakes made by the organization, discussed relevant regulatory standards, proposed preventive steps to avoid future incidents, and emphasized the importance of education and training. By implementing these recommendations, the organization can ensure safer and higher quality patient care.
