HSC 450 Patient Safety and Quality Improvement

HSC 450 Course Reflection

Name: Anthony Lund

eportfolio URL: https://sites.google.com/coyotes.usd.edu/anthony-lunds-eportfolio/home

1. Begin reflecting by reviewing the course objectives. Pick any four to describe how the objectives were met in your newly developed understanding and awareness of patient safety and quality improvement.

a. 1. Understand the magnitude of patient safety issues within the U.S, healthcare system.

As a medical professional, I knew there were many safety issues in healthcare, but not to the extent explained to us in our course book. The amount of medical errors alone was an eye opener. I had assumed that technology would help decrease some of these errors, but then I learned that people use the technology as a crutch and rely on it to be right all the time. I think it is good that practices and policies are being put in place to help prevent issues before they arise. With individuals being protected from reporting, it is a welcomed sight to see that reporting has gone up and issues have started to decrease.

b. 3. Identify the various roles that healthcare team members play in patient safety.

Everyone that works in healthcare play an important part in patient safety, whether they are clinical or non-clinical. An administrative employee can place information from a patient in a different patient’s personal file. Housekeeping can perform a fast and unthorough cleaning and leave an area contaminated. A tech or a nurse can carry a contaminant from patient to patient if they do not sanitize their hands or equipment. A doctor can give a patient a wrong diagnosis and prescribe a harmful treatment if they do not ensure that they have the right patient and patient information.

c. 9. Appreciate the term ‘culture of safety’ as a concept in healthcare practice.

Culture of safety in healthcare is when safe behaviors are rewarded and unsafe are discouraged. A culture of safety can affect employees and patients by ensuring everyone feels safe in their respected environments. Formal evaluations and peer pressure to do the right thing are helpful because people generally want to appear competent. This also allows for potential issues to be reported without repercussions. Blame is set off to the side so that the contributing issues, if any, can be looked at and remedied.

d. 11. Understand that errors occur as a result of many factors: cognitive, psychosocial, environmental and task related.

Due to the nature of healthcare, it is often chaotic with multiple events happening at once. If someone is relatively new at performing a task, their focus may be on one thing happening, but if a person gets too overconfident in a task, they might not be focusing as much as they should. People can also be distracted by thinking of what is going on in their personal lives, or tired from working too much, and make mistakes. The environment is a big factor too because someone may not be familiar with where things are and unfamiliar with certain equipment. People also may not be fully trained at a task and are afraid to ask for clarification because of fear of seeming incompetent.

2. a. Describe your overall expectation for this class and;

I have seen this class for the past few years since it is required and was excited to take it when it finally came up in my schedule. I feel that patient safety is of the utmost importance because it is our job to ensure the best possible outcome for the patient. I wanted to learn every aspect of safely providing patient care, and I feel that this course accomplished that through our required reading and the IHI modules.

b. Provide three main takeaways from this course (nuggets of information or “A-ha moments”) you were not aware of before this class.

1) My first takeaway from the course was when I learned about “culture of safety”. I have heard of “just culture” but not this. I think that it is a great system because it allows amnesty. I feel that people will feel safer reporting issues, and if they happen to cause one.

2) My second takeaway was when I learned about CQI. I believe CQI is a necessity in every healthcare program because it is a never-ending process. I like how it takes a proactive approach instead of focusing on the past to prevent issues.

3) Finally, I enjoyed learning how to interpret data on run charts in our IHI courses. I have heard of run charts, but now I know exactly what one is and how to read it. I feel that this will be an especially important aspect that I will be able to use for the rest of my career.

3. Provide three ideas, facts, and/or content (IFCs) that can be directly exercised or correlated into use for college, career, personal life, and future activities.

My first idea that I will carry on after this course is incorporating a culture of safety. I feel that this is so important for everyone, whether it is in healthcare or a different type of business. People should be able to freely speak about safety issues without fearing repercussions. The second thing that I will retain is learning about why things go wrong. I understand that people do make mistakes, and no matter what you do to prevent this, it will still happen because of the human factor. People have lives outside of work and this often carries over into the workplace because there is no switch to shut it off. They could have had a death in the family or going through a divorce. Their mind is wandering, and they are worrying about that and that is when accidents happen. The best way to prevent this is to help take away some of the areas of concern, like organizing medications and having different colors representing different things. The next thing is just to remember that what we do is all about the patient. If the potential patients do not have trust in a certain healthcare facility, they will seek out one that they do trust. I want to carry all the information that I have learned and help incorporate it into my workplace by reaching out and letting management know about practices that they are not incorporating.