Quality Improvement Report: Assessing Risk and Harm in Healthcare

This report focuses on quality improvement in modern healthcare systems, emphasizing the shift towards reducing avoidable errors and enhancing operational efficiency. It explores the complexity and risk inherent in healthcare, advocating for preventive measures to foster a culture of resilience and minimize patient harm. The report delves into risk management strategies, including identifying, analyzing, and controlling risks to improve service quality and protect patients. It discusses developing a safety culture through leadership commitment, teamwork, and flawless reporting. Furthermore, it examines the application of the Haddon framework for injury epidemiology and the importance of patient disclosure. The report underscores the need for healthcare providers to be protective of patient rights and discloses adverse events when necessary, aiming to create a healthcare environment focused on zero avoidable harm.

Running head: QUALITY IMPROVEMENT
Quality Improvement
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Author Note

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The modern health care delivery systems are subjected to significant amount of shift
of focus as the organizations are observed to focus significantly in reducing the number of
unforced errors that results in the increment ion the number of deaths. The organizations are
observed to be notably concerned with the capital budgets and the increment in the
operational efficiency in order to reduce the number faults in the health care centres along
with the evolution of the new models in the health care delivery system. As the modern
health care system is significantly costly, complex and filled with risk elements, the
organizations are in need to focus in the preventive measures. The paper is dedicated in the
developing consistency and resilience into the culture of the health care providers in order to
create a state of zero avoidable harms.
Background:
As mentioned earlier the modern health care system is significantly complex and
expensive. The complexity of the operations ensures the criticalness of the service. Several
studies in this sectors are able to confirm that the patients are harmed by the medical errors
9.2% of the total time where deaths took place in 7.4% of these events. 43.5% of these events
are avoidable. Apart from the cancer and the heart disease, the medical errors are third most
common source in the list of the cause of deaths.
Development of Resilience:
The development of the resilience with the focus of the zero avoidable harms requires
proper risk management strategy which needs to be introduced into the work culture of the
health care providers. The strategies re mentioned below:
Identification of the risk:
Finding out of the faults that are existing in the system.
Analysis of the risk:
The proper collection of the information and the data which will be suitable for the
analysis and the application of the appropriate methods.
Controlling Risk:
The analysis will help in formulation and implementation of the effective strategies to
manage the avoidable errors in the positive manner.

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Risk Management:
The measurement of the quality is achieved by examining whether a service or a
product is focused towards the patients, effective and safe. The objective of the clinical risk
management is to improve the quality of the services of the healthcare providers to protect
the patients. The definition of the organizational accidents are observed to incorporate the
spreading of fire in the operating room or the wrong judgement of the health issues of a
patient along with wrong surgery on the patients.
The health care providers will generate several benefits from the learning that near
misses offer, in the below mentioned form.
Firstly, the frequent occurrence of the near misses which is significantly higher than
the number of adverse events, enables the quantitative analysis. Secondly the number of
barrier in the data collection will be significantly less and in that case it will allow the
analysis of the interrelations of small failures. Thirdly Hindsight bias will be significantly
reduced by the strategy.
Engineering a culture of safety:
Organization culture is observed to be better shaped by shared practices rather than
the rules and regulations imposed by an organization. A strong safety culture is observed to
include a robust leadership commitment, effective teamwork, support and encouragement
from the fellow team members, rust in the communication along with the mutual importance
on the safety. Apart from that, flawless reporting and analysis is also a high contributing
attribute in the safety culture.
Application of the risk management concepts:
The application of the risk management concept is best practised when the whole
causal system is evaluated rather than only one root of the cause. Haddon’s framework on the
injury epidemiology is a significant approach in this case. The strategies that Haddon’s
prescribed approach incorporated for reducing the losses includes reduction and prevention in
the amount of energy arranged, modification or prevention of the rates and the spatial
distribution along with the release of the energy. Along with that the usage of the barriers will
also be significant in separating the energy from the susceptible structures. The strategies of
Haddon also includes the modification and strengthening of the structures capable of

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transferring energy to the people. Haddon also prescribed that it is better to follow the steps
like detect, counter, repair and rehabilitate when an injury occurs.
Role of Risk Management and Patient Disclosure:
The health care providers have to be protective to the rights of the patients. The
disclosure of the adverse events will only take place in cases where the perceptible impacts
are not explained and have the capability to cause significant amount of risk. Apart from that
the disclosure will also take place if there is a change in the patient’s health and that has the
potential to pose risk in the future health of the patients.

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Bibliography:
Johnson, J. K., & Sollecito, W. A. (2018). McLaughlin & Kaluzny's Continuous Quality
Improvement in Health Care. Jones & Bartlett Learning.