NR 532 Week 4 Discussion: Licensure and
Accreditation
The number of malpractice claims at your facility has doubled in the last quarter. Discuss a
strategic plan to reduce the number of claims. Be specific with your example and
explanation.
Malpractice occurs when a healthcare professional or organization causes harm to a patient
through not following standards of care or negligence. If the number of claims have doubled in a
quarter, this would indicate a serious concern for lack of quality care, patient safety, and
satisfaction. The first strategy I would implement is to perform a root cause analysis (RCA) on
each claim to determine why and how the standards of care were not met. Through this analysis,
an action plan would be created to correct the errors so they would not be repeated.
The second strategy I would focus on is educating and creating a “just culture” environment with
the goal to move towards being a high reliability organization (HRO). Just culture is a
mechanism to evaluate if an error occurred due to human error, reckless behavior, or at-risk
behavior (Ulrich, 2017). Using this mechanism helps hold people accountable and determine
what type of corrective action is needed. Establishing a “just culture” environment supports the
movement towards a HRO by creating a safe culture for reporting errors that does not focus on
placing blame (Quigley & White, 2013). It acknowledges that errors do happen and helps the
organization address and prevent the same error from happening again. A HRO is an
organization that is high-risk, dynamic, turbulent, and potentially hazardous, yet operate nearly
error-free. To become error-free, an organization must know what their errors are and be able to
drill down on each one of them. So, it is essential to create a culture and environment where
every error, regardless of the severity, is reported.
Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and
improvement in high reliability organizations. Online Journal of Issues in Nursing, 18(2), 1. doi:
http://dx.doi.org.chamberlainuniversity.idm.oclc.org/10.3912/OJIN.Vol18No02Man05
Ulrich, B. (2017). Just culture and its impact on a culture of safety. Nephrology Nursing Journal,
44(3), 207-259. Retrieved from https://www.annanurse.org/resources/products/nephrology-
nursing-journal
Identify a patient-safety issue at your current or previous organization. Share your plan to
prevent or eliminate the issue.
During a recent Colorado Department of Public Health and Environment (CDPHE) investigation
at one of our sister hospitals, a gap was identified in the hospital’s pre-cleaning process prior to
sterilization of surgical instruments between July 21, 2016 and Feb. 20, 2018 for orthopedic and
spine surgical procedures. As part of their standard quality management process, they track
infections and found no evidence of patient harm. They took immediate action to remedy the
gap discovered, and recent survey results released by the Joint Commission, which accredits
hospitals in the United States, revealed no errors in their current processes or protocols.
This study source was downloaded by 100000801755870 from CourseHero.com on 03 -22-2022 07:41:56 GMT -05:00
https://www.coursehero.com/file/36485250/Week-4-Discussiondocx/
Accreditation
The number of malpractice claims at your facility has doubled in the last quarter. Discuss a
strategic plan to reduce the number of claims. Be specific with your example and
explanation.
Malpractice occurs when a healthcare professional or organization causes harm to a patient
through not following standards of care or negligence. If the number of claims have doubled in a
quarter, this would indicate a serious concern for lack of quality care, patient safety, and
satisfaction. The first strategy I would implement is to perform a root cause analysis (RCA) on
each claim to determine why and how the standards of care were not met. Through this analysis,
an action plan would be created to correct the errors so they would not be repeated.
The second strategy I would focus on is educating and creating a “just culture” environment with
the goal to move towards being a high reliability organization (HRO). Just culture is a
mechanism to evaluate if an error occurred due to human error, reckless behavior, or at-risk
behavior (Ulrich, 2017). Using this mechanism helps hold people accountable and determine
what type of corrective action is needed. Establishing a “just culture” environment supports the
movement towards a HRO by creating a safe culture for reporting errors that does not focus on
placing blame (Quigley & White, 2013). It acknowledges that errors do happen and helps the
organization address and prevent the same error from happening again. A HRO is an
organization that is high-risk, dynamic, turbulent, and potentially hazardous, yet operate nearly
error-free. To become error-free, an organization must know what their errors are and be able to
drill down on each one of them. So, it is essential to create a culture and environment where
every error, regardless of the severity, is reported.
Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and
improvement in high reliability organizations. Online Journal of Issues in Nursing, 18(2), 1. doi:
http://dx.doi.org.chamberlainuniversity.idm.oclc.org/10.3912/OJIN.Vol18No02Man05
Ulrich, B. (2017). Just culture and its impact on a culture of safety. Nephrology Nursing Journal,
44(3), 207-259. Retrieved from https://www.annanurse.org/resources/products/nephrology-
nursing-journal
Identify a patient-safety issue at your current or previous organization. Share your plan to
prevent or eliminate the issue.
During a recent Colorado Department of Public Health and Environment (CDPHE) investigation
at one of our sister hospitals, a gap was identified in the hospital’s pre-cleaning process prior to
sterilization of surgical instruments between July 21, 2016 and Feb. 20, 2018 for orthopedic and
spine surgical procedures. As part of their standard quality management process, they track
infections and found no evidence of patient harm. They took immediate action to remedy the
gap discovered, and recent survey results released by the Joint Commission, which accredits
hospitals in the United States, revealed no errors in their current processes or protocols.
This study source was downloaded by 100000801755870 from CourseHero.com on 03 -22-2022 07:41:56 GMT -05:00
https://www.coursehero.com/file/36485250/Week-4-Discussiondocx/
