6NH095 Assessment: Critical Analysis of a Patient Safety Incident Sample

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Introduction - 6NH095 Assessment Critical Analysis of a Patient Safety Incident Sample

The patient safety incident implies the undesirable event which may cause harm to the patient when experiencing the care facility or services. This includes harm from the result of illness which does not meet the patients' expectation for enhancement. The current report is based on the case scenario of Gary, who is 38 years old, and has a history of mental health problems. He had extreme paranoid behavior, mood changes as well as auditory delusions. This report will emphasize on risk management guidelines that need to be followed for offering secured care environment to Gary. Further, it will also shed light on risk management practices or aspects in the clinical activities which include evaluation as well as reduction in the risk of injury to the patients. Strategies implemented across the health systems enhance effectiveness as well as patient experience. The aim of the report is to emphasize on risk management procedure which facilitates the clinicians to support their decision-making by communicating the systematic assessment of people. It will also highlight how Lewin and Kotter’s 8-step model contributes in implementing as well as managing change. This content provides valuable help with assignment writing and is relevant for the 6NH095 Assessment.

Main body

The main body of this 6NH095 Assessment Critical Analysis of a Patient Safety Incident Sample thoroughly examines key factors contributing to patient safety incidents through the case of Gary. It identifies critical issues such as inadequate risk assessment, poor communication and information-sharing failures, and the complex social determinants impacting patient outcomes, including homelessness and lack of social support. Moreover, cognitive biases in clinical decision-making and insufficient interdisciplinary communication further exacerbate risks to patient safety. The analysis emphasizes the importance of comprehensive risk management training, cultural competence, and interdisciplinary care coordination frameworks to enhance healthcare delivery. It highlights how Lewin’s change theory and Kotter’s 8-step change model can facilitate effective implementation of risk mitigation strategies within healthcare settings. These insights provide essential guidance for clinicians aiming to improve patient safety and care quality, making this report invaluable for students seeking help with assignment writing related to healthcare risk and safety management.

Insight

Inadequate Risk Assessment and Follow-Up Care

Inadequate follow up-treatment signifies to the case where the healthcare professionals fail to take follow up on the diagnosis, treatment as well as aftercare. The discharge plan of Gary does not include follow-up behavioral health appointments as well as other activities such as getting lab work completed, obtaining medications as well as attending support groups. Impaired sustained attention has been considered as a major factor in determining the poor functional outcomes of Gary across the behavioral disorders (World Health Organization, 2021). According to NICE guidelines for healthcare in England and Wales assists health and social care professionals to prevent ill health, enhances quality of care as well as encourages good health. In the case of Gary, failure of safe care transitions by GP after the hospital discharge resulted into the worsening symptoms as well as an extended period of mental illness (Azyabi, Karwowski and Davahli, 2021). 

6NH095 Assessment: Critical Analysis of a Patient Safety Incident Sample

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Communication and Information-Sharing Failures

According to Wiegmann et al, (2022) the staff conducting the mental health assessment has not contacted Darren who is Gary’s wife to obtain his perspective. Family members play a significant source of collateral information regarding the patients' past history. Professional patient rapport is the significant part which creates confidence among the patient to be active in their treatment regimens. Efficient communication is the main key which keeps the care team informed as well as ensures that patients receive a high standard of care. However, Wiegmann et al, (2022) said that the major effects of the poor communication within the health & social care are reduction in the quality of care, wastage of resources, poor patient outcomes as well as high healthcare costs. This also has the negative effect on the patient as well as staff satisfaction. The poor communication among the practitioners as well as patients or their families leads to life-threatening complications. This may result into the range of negative outcomes like patient dissatisfaction, reduced adherence to treatment as well as inefficient use of resources. Poor communication can result in the range of negative outcomes like reduced adherence to patient dissatisfaction and adherence to treatment.

Homelessness and Lack of Social Support

Hodkinson et al, (2022) ascertained the fact that unsheltered experience of Gary leads to a high rate of serious mental illness. Individuals experiencing the homelessness have elevated the rates of mental health conditions as well as substance use disorders. Unhoused people are more probable to experience the unmanaged chronic physical as well as mental health issues. Homeless people with the mental illness are more vulnerable to violence. Gary was not qualified for the local authority housing as well as he slept in his van and on sofas which lead to worsen his mental health conditions (Wiegmann et al, 2022). People experiencing the homelessness face discrimination that leads the barriers to accessing healthcare. Those who experience the long-term housing affordability stress have a major influence on the mental illness related to the emotional, social as well as mental functioning. Or people with homelessness, small expenses can be the barrier in accessing the mental health care. Nevertheless, Cho and Steege (2021) argued that offering housing to people experiencing the homelessness can assist in preventing the exacerbation of the mental disorders. Homelessness is the complicated issues as well as social determinants of the health which can be served as a key factor in handling as well as developing the comprehensive solutions to prevent homelessness. However, displaying vulnerability facilitates to make relations with their patients.

Mulac et al, (2021) mentioned in their study that to reduce the hospital readmissions, efficient discharge planning as well as appropriate post-discharge support are the key needs. This may contribute in preventing the issue of homelessness for the patients. Discharge from the hospitals to home needs the efficient transfer of information from the clinicians to the patient as well as family to mitigate the adverse events. Homelessness is the major deprivation of access to housing and a kind of social exclusion for the loss of dignity. It has been analyzed that the mental health conditions are four times more probable to poor housing has made their health worsen. Homeless people have the high risk rate of premature mortality which leads to suicide as well as unintentional injuries. On the other hand, Moll et al, (2022) said that mental health nurses need to support the patients with the complex requirements who are homeless. Voluntary supportive services are provided to enhance housing stability as well as prevent the returns to homelessness as opposed to handling the predefined goals prior to the stable housing entry. People experiencing the homelessness require the time for leisure where they can feel relaxed from the life challenges as well as experience something they love. Homelessness has emerged as the public health priority with the rising number of vulnerable people regardless of advancement in social welfare. Mental health nurses support the patients with the complicated requirements who are homeless which need to deliver support in care.

Involvement

Cognitive Bias in Clinical Decision-Making

McGrath et al, (2021) defined cognitive bias as distortions in the decision-making which lead to poor health outcomes. Cognitive bias in the healthcare creates diagnostic errors as well as delay in the treatment. This typically leads to distortions in the decision making which can lead to poor health outcomes. Anchoring bias can delay the vital testing for as well as diagnosis of deadly medical conditions like pulmonary embolism. Shared understanding may include the biases regarding the mental health status of the ethnic minority patients. Gary with mental illness faced stigma and was viewed in a negative manner as well as feeling ashamed (Hodkinson et al, 2022). Social stigma as well as discrimination can make the mental health illness worsen as well as stop the people from getting the assistance they require. However, medical care on the basis of interdisciplinary co-operation is linked with the patient safety as well as low hospitalized rates.

Inadequate Interdisciplinary Communication

Johnstone et al, (2021) defined that healthcare staff failed in involving Darren which resulted in conflicts as well as communication challenges. Communication breakdown is the major reason for adverse events in the clinical routine. This highlights the requirements for clear communication channels as well as mutual respect among professionals. Communication gaps as well as other challenges can lead to worsen healthcare as well as patient safety risks. However, Bates et al (2023) said that efficient communication among staff motivates teamwork, encourages continuity as well as clarity in the patient care team. With efficient communication, the care professionals can make the patients more satisfied as well as adhere to their treatment plans. This is the key to keeping the care team informed as well as ensuring that the patient receives the standard care. Efficient communication leads to improved decision-making, resource allocation, strategic planning as well as policy development which benefit the patient care as well as operational effectiveness. An efficient approach leads to enhance the healthcare outcomes as well as organizational efficiency.

Lack of Staff Training on Risk Management and Social Determinants of Health

Schroers, Ross and Moriarty (2021) assessed that lack of healthcare professionals' training is the major challenge within healthcare. The major impact of the lack of training in a care setting is the Gary’s quality of care. This has led to delayed treatments, high costs as well as enhanced the risk of spreading illness. Several healthcare professionals as well as leaders are less interested in the staff training because of high costs. The lack of training in the care setting can cause poor management, lack of responsibility as well as standard work atmosphere. Contextualizing care is the procedure of adapting the research evidence for the patient's life context. Failing to handle the contextual factor when it is feasible leads to contextual error. Nevertheless, the patient-centered care plan emphasizes on the unique requirements of the patients.

According to Guttman et al (2021) social determinants of mental health comprise for the set of structural situations in which the individuals are exposed with the conception to death which impact their mental health outcomes. Social contextual data are captured prospectively in the comprehensive as well as structured manner which leaves with the knowledge gap. It has been evaluated that factors which delay mental illness treatment include a lower level of knowledge regarding the mental illness as well as discrimination against the individuals with the mental illness. The issue includes the disconnection in the policy areas of the housing, income supports as well as mental health. The key reason for the delayed discharge is patient not having specific housing to be discharged to that meets their requirements. On the other hand, Ohba, Tanigawa and Liutsko (2021) argued that training of mental health care providers in the suicide prevention needs to be augmented by handling systemic issues in the provision of mental health care as well as issues which make the suicide prevention challenging.

Chirra (2021) stated that the image of homelessness evokes the stereotypes of the incompetence, laziness as well as even criminality. Social stigma as well as discrimination can make the mental health illness worsen as well as stop the people from getting the assistance they require. Cultural competence training is the key strategy in enhancing health results as well as reducing disparities in the rural areas (Johnstone et al, 2021). The training shows that staff enhances their skills as well as assist them in offering better care for the patients. Cultural competence has been seen as a pillar for reducing the disparities with cultural sensitivity as well as unbiased quality care. Organizational culture plays a vital role in the plans, decisions as well as actions of the workplace along with offering quality care for the patients.

Improvement

Comprehensive Risk Management Training

Zhang et al, (2022) identified in their study that training of healthcare staff is the key to reducing the mental health treatment gaps as well as enhancing care. The care staff trained in the evidence-based treatment needs to be offered with the treatment of suicidality with the recognized suicide risk. This needs equipping the healthcare employees to understand the way social determinants of health influence the patient as well as communities. Understanding the influence of stigma in the various cultural contexts is vital which aims to inform the culturally nuanced strategies.

Stigma reduction training assists the care providers in developing the specific skills to work efficiently with the stigmatized groups. ASIST will contribute in enhancing attitude, skills, competence as well as confidence related to the suicide intervention in the range of populations. Holistic care enhances the depth of the care providers understanding of the patients as well as their requirements. This will help them in self-care as well as assist them in performing the daily activities (Guttman et al, 2021). By incorporating the range of treatment methods, holistic care bridges the gap between traditional medicine as well as alternative therapies. Offering continuous learning opportunities can enhance new ideas as well as assist the organization in reaching its objectives. This will also reduce absenteeism as well as lead to higher productivity.

Kurt Lewin has established the change model which includes three key steps such as unfreezing, changing along with refreezing. In the unfreeze stage, the manager needs to offer training on risk-aware culture which empowers staff to recognize potential challenges identify procedures as well as communicate concerns. In change, open communication channels as well as a culture of risk awareness support the efficient risk management. Training primary care physicians in depression identification as well as treatment prevents suicide. In the last stage, reinforcing regular updating competency framework changes healthcare industry standards as well as obtaining staff feedback on the competencies (Caldas et al, 2021). The healthcare providers by embracing the holistic care include identifying the multifaceted nature of the human health as well as handling the requirements of people.

Interdisciplinary Care Coordination Framework

Aiken et al (2023) ascertained the fact that collaboration care promotes the seamless information exchange as well as collaboration among the care providers which ensures the smooth transition in the care settings along with enhancing the patient’s experiences. This ensures the smooth transitions in the range of healthcare settings as well as enhances the experience of patients. Collaborative care focuses on preventing interventions as well as health promotion programs which enhance the community health outcomes. With the collaboration, the care professionals can incorporate the health education initiatives as well as promote wellbeing in the community (Bakerjian and Wasserman, 2024). By engaging the community and tailoring the interventions can meet the needs of the patients. There is a rising emphasis on motivating patients to partner with the care providers as well as being actively included in decisions regarding their care.

Al-Worafi (2023) examined care coordination handles the critical gaps in the healthcare offering like transition among the care settings. This will ensure the continuity of care which prevents the information loss as well as reduce the risk of adverse events. Care coordination ensures the smooth transition among the levels of care which reduces the risk of complications as well as enhances the health outcomes. Regular exercise makes sure that the team members are updated with the latest technologies as well as practices (Petruzzi et al, 2024).

Kotter’s 8-step change model helps in implementing the change within the organization. Strategic planning is the technique where the company defines a bold vision as well as creates the plan with the goals of reaching the future. Healthcare professionals are expected to remove the challenges by implementing the change as well as enhancing innovation (Silvola et al, 2024). Corporate training and development assist the organization to enhance the workers' productivity as well as performance in the job roles. Employee development training will offer opportunities for workers to gain the new skills as well as competencies.

Conclusion

In conclusion, patient safety is the challenge which requires specific skills and knowledge in the various areas such as human factors. Enhancement of the patient’s safety needs the reliable organization that strives to ensure the quality care services. The robust risk management framework assists in identifying the threats and plans how to deal with them efficiently. Gary with the chronic mental illness needs the high rate of care. It has been analyzed that communication is required to be improved as well as patient vulnerability can be reduced with the strong emphasis on interpersonal aspects. To promote the patient’s safety, high level of emphasis need to be placed on healthcare staff training as well as communication which contributes in preventing the future incidents. This ensures collaborative understanding along with open communication among the care professionals as well as patients.

References

Books and Journals

• Aiken, L.H., Lasater, K.B., Sloane, D.M., Pogue, C.A., Rosenbaum, K.E.F., Muir, K.J., McHugh, M.D., Cleary, M., Ley, C., Borchardt, C.J. and Brant, J.M., 2023, July. Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. In JAMA Health Forum (Vol. 4, No. 7, pp. e231809-e231809). American Medical Association.
• Al-Worafi, Y., 2023. Patient safety in developing countries: Education, research, case studies. CRC Press.
• Azyabi, A., Karwowski, W. and Davahli, M.R., 2021. Assessing patient safety culture in hospital settings. International journal of environmental research and public health, 18(5), p.2466.
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