Patient Safety Report: Analyzing Diagnostic Errors and Patient Care

This report delves into the critical issue of patient safety within healthcare organizations, emphasizing the importance of protecting patients from preventable errors. It explores the relationship between patient safety and Human Health Service Management, highlighting the impact of errors on the patient-healthcare organization dynamic. The report identifies diagnostic and medication errors as key concerns, advocating for organizational attention to mitigate biases and improve patient outcomes. It examines ethical frameworks and legal acts, including the role of nurses and the impact of the Affordable Care Act. The assessment identifies issues such as delayed test results and inadequate information systems, leading to medical errors. A literature review supports these findings, underscoring the need for improved communication and the implementation of lab automation. The report includes a case debriefing strategy, proposing lab automation as the most effective solution to reduce diagnostic errors. It concludes with a critical analysis of the issue, advocating for support from higher authorities, cooperation from pathologists, and patient involvement. Future considerations include the implementation of advanced software and automation to enhance communication and improve patient safety. The report also addresses digital communication strategies and includes a Q&A session with peers.

A N I S S U E O F H E A LT H A N D H U M A N
S E R V I C E
Patients safety

Definition and relation with HHSM
Patients safety is basically the act of protecting the patients in any healthcare
organization and if the organization is unable to protect a patient from any
preventable errors, then patients safety becomes a main issue (Daniel &
Makary, 2016).
It is associated with the Human Health Service Management as the issue has
huge impact on the relationship between patients and the healthcare
organizations (Singh & Sittig, 2015).

Personal value and how to mitigate
bias
Patients safety should the first priority for any healthcare organization.
Many hospitals and clinics are concerned regarding this issue as sometimes
they become the victim of some unacceptable errors like diagnostic error,
medication error (Kessler, Cheng, & Mullan, 2015).
The attention from the authority of the healthcare organization is useful in
mitigating the bias (Dauwalder et al., 2016).

Ethical framework and legal acts
Nurses play an important role in the patients safety by incorporating the ethical values to it.
 When the medical error goes wrong, the requirement of staying honest and open is necessary.
Taking responsibility of other colleagues is also very challenging and requires ethical values.
AHRQ, Agency for Healthcare and Research which is the lead federal agency has set many rules
and acts in improving patients’ safety (Shekelle et al., 2016).
Under the Patients’ protection and Affordable Care Act, (ACA) 2010, US Supreme Court has legal
act in this regard (Vincent & Amalberti, 2016).

Findings from the assessment
Assessment checklist is used to identify possible issues.
The assessment checklist can be used to know what the assessment of patients safety
reflects (Khullar, Jha, & Jena, 2015).
 First of all organizational environment needs to be checked that why the patients safety is
the concern. It shows that delay in providing the test results is a problem which reflects a
weak leadership.
There is issue regarding the adequacy as well as appropriateness of information system
that results in medical error.

Literature review
Various studies and scholarly articles are there regarding patients’ safety in healthcare
organizations.
Patients safety has become the main concern in all hospitals (Schmidt et al., 2017).
Many safety risks are there that includes medication, diagnosis, communication and
others (Lyratzopoulos , Vedsted, Singh, 2015).
According to some authors, knowledge and skills of healthcare professionals can also
create safety issue of patients’ (Zwaan & Singh, 2015).

Case debriefing strategy
 For the case debriefing strategy of this issue, the first step is to identify the main problem and in patients’ safety issue one of the main
problems is medical error (Edmonds et al., 2015).
 Next step is identifying the underlying assumptions. In this issue, medical error can be very dangerous as this can create life risk of a
patient.
 Next steep is structuring the involvement of stakeholders. All the pathologists and the lab professionals are involved as stakeholder
(Graber et al., 2014).
 The fourth step is to develop three different viable options in order to address the value. The options can be increasing communication
with the patients, analyzing the result twice to avoid confusion, and the last option is introducing lab automation (Ginter, Duncan, &
Swayne, 2018).
 The last option, which is introducing lab automation is most effective which can reduce diagnostic errors. It involves technology in the
analysis that helps in getting accurate result within time (Hammerling, 2015).
 So, in this issue implementing lab automation software can be most effective.

Critical analysis & decision making
process
I analyzed the patients safety issue after reviewing the whole mater and found
out the main source of the issue.
The main problem was medical errors due to delay and error in results of
diagnosis.
After the analysis I tried to find solution.
Implementing lab automation software was the most effective solution I found
and worked according to that.

What is need to be advocated
The support from the higher authority of the healthcare organization
will be required to implement the lab automation.
An approval or consent paper duly signed by the authority should be
kept for assistance.
All the pathologists should support the process to get success.
Cooperation from the patients is also required.

Future considerations
Manager should aware of the issue in future and they should focus to improve
the patients safety (Hallworth et al., 2015).
In future, more advanced software will be implemented to improve the
communication process between patients and lab professionals.
There will not be any error and the result and time will not be an issue.
The whole progress and system will work on automation in future for the
betterment.

Digital communication strategies
The issue regarding patients safety is common in healthcare organizations and it should be taken care with
more professionalism and improvement in the work practices.
With the help of digital communication strategy, at first the target audience needs to be set and then services
are needs to be provided to reach the goal.
Q/A session with peers in D2L
Question to peer 1: Do you think diagnosis error is dangerous?
Answer from peer 1: Yes, even it can create life risk for the patients.
Question to peer 2: Will introducing lab automation be helpful in reducing the error?
Answer from peer 2: Yes to some extent it will bring accuracy to the test results.

Works cited
Daniel, M., & Makary, M. A. (2016). Medical error—the third leading cause of death in the US. Bmj, 353(i2139), 476636183.
Dauwalder, O., Landrieve, L., Laurent, F., de Montclos, M., Vandenesch, F., & Lina, G. (2016). Does bacteriology laboratory automation reduce time to results and
increase quality management?. Clinical Microbiology and Infection, 22(3), 236-243.
Edmonds, E. C., Delano-Wood, L., Clark, L. R., Jak, A. J., Nation, D. A., McDonald, C. R., ... & Bondi, M. W. (2015). Susceptibility of the conventional criteria for
mild cognitive impairment to false-positive diagnostic errors. Alzheimer's & Dementia, 11(4), 415-424.
Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2018). The strategic management of health care organizations. John Wiley & Sons.
Graber, M. L., Trowbridge, R., Myers, J. S., Umscheid, C. A., Strull, W., & Kanter, M. H. (2014). The next organizational challenge: finding and addressing diagnostic
error. The Joint Commission Journal on Quality and Patient Safety, 40(3), 102-110.
Hallworth, M. J., Epner, P. L., Ebert, C., Fantz, C. R., Faye, S. A., Higgins, T. N., ... & Vanstapel, F. (2015). Current evidence and future perspectives on the effective
practice of patient-centered laboratory medicine. Clinical chemistry, clinchem-2014.
Hammerling, J. A. (2015). A review of medical errors in laboratory diagnostics and where we are today. Laboratory Medicine, 43(2), 41-44.
Kessler, D. O., Cheng, A., & Mullan, P. C. (2015). Debriefing in the emergency department after clinical events: a practical guide. Annals of Emergency
Medicine, 65(6), 690-698.

Works cited
Khullar, D., Jha, A. K., & Jena, A. B. (2015). Reducing diagnostic errors—why now?. The New England journal of medicine, 373(26), 2491.
Lyratzopoulos, G., Vedsted, P., & Singh, H. (2015). Understanding missed opportunities for more timely diagnosis of cancer in symptomatic
patients after presentation. British journal of cancer, 112(s1), S84.
Schmidt, H. G., Van Gog, T., Schuit, S. C., Van den Berge, K., Van Daele, P. L., Bueving, H., ... & Mamede, S. (2017). Do patients' disruptive
behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment. BMJ Qual Saf, 26(1), 19-23.
Shekelle, P. G., Sarkar, U., Shojania, K., Wachter, R. M., McDonald, K., Motala, A., ... & Shanman, R. (2016). Patient safety in ambulatory
settings.
Singh, H., & Sittig, D. F. (2015). Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual
Saf, 24(2), 103-110.
Vincent, C., & Amalberti, R. (2016). Safety strategies in hospitals. In Safer Healthcare (pp. 73-91). Springer, Cham.
Zwaan, L., & Singh, H. (2015). The challenges in defining and measuring diagnostic error. Diagnosis, 2(2), 97-103.