-Write a three-page paper outlining your design for a performance improvement project based on the near miss/great

Use Provided “Near Misses” and Great Saves Examples to Design a Performance Improvement Project in a Healthcare setting

Near miss events in the hospital setting are opportunities to improve the quality of hospital operation at all levels. There are several systems in use by several institutions to report near miss events. A near miss is an event that did not injured patient but had the potential to do so. There are two main ways to deal with near miss events. First, the reactive way, where the report of the near miss event is provided after the situation happened. Second, a proactive way where preventive methodologies are implemented prior any event happened. Both systems are important in the prevention process of near miss events. It is important to mention that root-cause analysis is a valuable tool when the never event happened and to analyze a near miss event since it will inquire and find evidence of the root cause of the problem. Sometimes the reasons are not very evident and further analysis is done following the root-cause analysis.

As mentioned earlier there are two main widely used systems: Occurrence Reporting Systems (ORS) and Failure Mode Effects Analysis (FMEA). The first method provides timely notification of near miss events to the risk manager after the event. The risk manager should use the information to make adjustments in procedures affecting the outcome of the situation under scrutiny. One of the problems with this approach is that staff member usually do not report near miss event because of fear of punitive action by management. Sometimes near miss event are not documented for the same reason. The second approach involves a proactive approach instead of a reactive approach. The Failure Mode Effects Analysis analyses near misses before they occur. The advantage of this approach is that staff is more willing to participate because of the elimination of punitive action by management.

A recent study by revealed that 47% of near misses are due to procedures errors. Therefore, immediate attention is required to the specific procedure that is responsible of the near miss. The most common areas were data chart mistakes, ordering and reporting results. Surprisingly, clinical knowledge and performance errors represented 2% of al the near misses (Crane et al., 2015). The success of the research work was due to the anonymous way to gather the information.

Gathering relevant data is the objective of any institution to make their processes more efficient and relevant. In order to stimulate the participation of all staff is crucial that the information is gathered anonymously otherwise the participation of caregivers will be minimal. The institution should create a web page accessible by staff with a universal access code to eliminate direct identification of staff. The information gathered by the anonymous system and retrieved by the risk manager. Data retrieved will help evaluate the near misses and provide remedial action.

The cases that were provided in the discussion have one factor in common which is advance directive. Patient’s have the right to provide advance directives and violation of those rights represent a serious burden to the caregivers. There are several provisions that can be taken into account to avoid never events in controversial area. The hospital should have in place a double check system for this important area. The first is the arm band where specifies the advance directives by the patient. Second, the room should have a writing board where the caregivers should write the advance directives instruction to alert any caregiver in case of a situation that requires a decision about resuscitate or not the patient based on advance directive. A common practice should be to verify the patient’s information every time a new shift starts. Medical emergencies are impossible to forecast, therefore the best way to prevent any problem is to be proactive especially in those areas that deal with advance directives.

The scope of this discussion is the non-harm events to patients or near misses. When it come to situations that harm the patient or violates patients’ rights the institution and the professional involved need to be held accountable. In 1999, the National Quality Forum was established as a non-profit organization. The mission of this organization was to improve the quality of American healthcare by a development of consensus-based standard for services (Kizer & Stegun, 2005). Is very important to distinguish between near miss to never events they are completely different situations an institutions should treat them different because of the patient implication of both.