Take some time to research the Patient Safety and Quality Improvement Act of 2005. This landmark piece of legislation continues to be a critical law for health care managers to follow. While promoting patient safety and quality of care, this act also caused (and continues to cause) some tension between improving the quality of care provided with acknowledging and reporting responsibility for error in the health care settings.

Review the three types of patient safety events that are reportable under the Patient Safety and Quality Improvement Act, and locate an example of such an event that has occurred under one of the three reportable categories. Then:

1. Clearly summarize the patient safety event. What (specifically) happened, what were the circumstances of the event, and what person(s)/position(s) was/were deemed to be at fault?
2. What stakeholders were involved? What was the role of each? Often, these events involve several stakeholders, so consider all parties carefully.
3. Articulate a specific plan for preventing this type of patient safety event from happening again. What (specifically) must change, be done differently, not be done, etc.?
4. On the last page of your assignment, draft an email to communicate the prevention plan to your employees. Be clear and concise in what your expectations are, and who is responsible for all parts of the plan’s implementation and monitoring.

Required Reading/Viewing

American Society for Health Care Risk Management. (2019). Different roles, same goal: Risk and quality management partnering for patient safety. Available at https://www.ashrm.org/sites/default/files/ashrm/Monograph.07RiskQuality.pdf

American Society for Health Care Risk Management. (2019). Healthcare risk management: The path forward. Available at https://www.ashrm.org/sites/default/files/ashrm/Executive-Summary_Risks-Rewards-Healthcare-Reform_FINAL2.pdf

American Society for Health Care Risk Management. (2019). The growing role of the patient safety officer: Implications for risk managers. Available at https://www.ashrm.org/sites/default/files/ashrm/Monograph.PSO.pdf

View:
Burke, J. & Green, C. (2016, October 6). Risk management 101 for healthcare providers [Video file]. Available at https://youtu.be/okTeoHYRqMc

View:
Escher, C. & Alton, G. (2016, June 27). Managing healthcare risk [Video file]. Available at https://youtu.be/3kqsTxTa1ow

Guler, P. H. (2017). Patient experience: A critical indicator of healthcare performance.
Frontiers of Health Services Management, 33(3), 17-29. Retrieved from the Trident Online
Library.

Santa, R., Borrero, S., Ferrer, M., & Gherissi, D. (2018). Fostering a healthcare sector
quality and safety culture. International Journal of Health Care Quality Assurance, 31(7),
776-80. Retrieved from the Trident Online Library.

Read Chapter 8, pp. 125-141, in:
Spath, P., & Kelly, D. (2017). Applying quality management in healthcare: A systems
approach (4th ed.). Health Administration Press. Retrieved from the
Trident Online Library.

Strickler, S., Gupta, R. R., Doucette, J. T., & Kohli-Seth, R. (2018). A quality assurance
investigation of CLABSI events: Are there exceptions to never? Journal of Infection
Prevention, 19(1), 22-28. Retrieved from the Trident Online Library.