Quality and Safety Gap Analysis

Quality and Safety Gap Analysis

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  • Type of paperResearch Paper
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A Systemic Problem in the Organization, Practice Setting, and Area of Interest.

Medical errors and mistakes severely affect the patients and some end up killing them. The errors and mistakes occur in every practice setting, whether a big or small healthcare facility in various nations around the globe. According to research (Rothschild et al., 2005), the majority of these mistakes are rendered either deliberate, unintentional or preventable. The research reported a surprising patients’ deaths emanating from these mistakes and laid out a broad approach to minimizing the preventable medical mistakes and errors.

In 2015, seven patients receiving treatment under the intensive care unit unexpectedly lose their lives in our level Four healthcare facility, Hari Hospital. According to the preliminary details on the cause, the patients died as a result of cut off of their oxygen supply to their ventilators. The details of why and how this catastrophe happened are still questionable with different opinions reported to the press. The blame game started to heat up as the hospital’s authorities took it to the hospital’s contractor company in charge of the oxygen supply. In response to the unanswered questions, I took the charge engrossing the checks and counter checks built into and outside the system to assist in detecting and addressing the medical mistakes in a timely fashion, with the key aim of avoiding such tragic errors in the organization.

Proposed Practice Changes

The urge to improving quality and safety outcomes in this facility stems from the appropriate practice changes that would work in collaboration to avoid these tragic errors in medicine (Rothschild et al., 2005). In response to that, the significance of time-outs before any medical procedure, checklists before any surgical administration, and observance of the conventional hospital’s protocols should never be overlooked at any circumstance. I would propose the three practices with the effect that as much as mistakes and errors happens, they usually provide a sufficient condition for checks and counter checks for every surgical procedure before and after administration.

Prioritized Proposed Practice Changes

With respect to the three practice changes, we have a keen look at how exactly they provide sufficient condition for the health practitioners and the organization. In the operating room, the time-out is similar to a surgical safety and quality checklist (Rosswurm & Larrabee, 1999). Immediately the patient is moved to the operating room for surgical administration, everyone involved in the administration – the health surgeon, the patient, the nurses and the anesthesiologist, should reach an agreement on the identity of the patient, the surgical procedure which is to be administered, and the location of the planned surgical process. According to Rothschild et al., (2005), besides involving quality patient care and improved performance of the surgical team in the operating system, time-out is considered a safety measure that avoids injury resulting from the wrong location or administering the wrong procedure. It may be repeated prior to the actual incision for detection of any error.

Hospitals checklists have been regarded to solve various healthcare problems and mistakes especially with the current incline of medical errors. The checklists are regarded significant whenever there are benefits in performance standardization, time, the number of surgical procedures is complex for memory commitment and, the surgical location enables a physical list to be retrieved and applied (Rosswurm & Larrabee, 1999). In response to the tragedy at Hari Hospital, a checklist confirming monthly check-up of the oxygen supply plant could have barred the catastrophe. A backup oxygen supply should have been in place.

The medical protocols are established with the key aim of advancing care quality, minimizing the practice variation and ensuring that evidence is actually applied when deemed appropriate. The protocols involve a series of developed recommendations to help the medical surgeon and their patient’s decisions about suitable healthcare for a particular medical procedure and circumstances (Rosswurm & Larrabee, 1999). In the case of Hari Hospital, a protocol defining what to do in an event of abrupt oxygen cut off to the ventilators could have equipped the practitioners and nursing staff with the appropriate approach to intervening in a well-timed technique.

How Proposed Practice Changes will Foster a Culture of Quality and Safety

If the three proposed practice changes are executed, they will foster a culture and quality safety in the organization as follows. A well-defined time-out will break the ice at the onset of a day, with a reverent and respectful discussion of the phases of the surgical operation with the surgical team and the patient, as well as the possible challenges and a plan B if any is required. The time-out will provide a platform for the practitioners to share their experiences and thoughts, which will deem to set up the team for a good day every time (Scott et al., 2003).

The efficacy of executing checklist in healthcare will foster various significant benefits for varying results: the success of the proposed practice changes will instill complex, organizational and cultural change efforts, not only the checklist itself but also the outcomes that may be confounded by the incorporation of the technical components, with the local contexts and execution results (Scott et al., 2003).

The effective implementation of clinical protocols will ensure a culture adherence in practice that would instill all the healthcare practitioners in Hari Hospital and the patient in making decisions about appropriate healthcare for a particular health procedure and circumstances.

How a Particular Organizational Culture or Hierarchy might affect Quality and Safety Outcomes

According to Scott et al., (2003), organizational culture or hierarchy refers to the shared workers’ concepts in regards to the organizational processes, policies, and practices, which in turn aids as the indicator for the various set of behavior that is content and supported in work settings. The culture in organizations is used to examine why the organization tends to emphasize on various priorities that affect safety and quality of outcomes. Various reports (Rothschild et al, 2005), have indicated that different degree of quality and safety performance – quality improvement activities, patient-care quality and efficiency, provider team’s effectiveness and patient satisfaction – affects the outcome. For instance, patient-care quality and efficiency involved in length of stay may constraints people who need treatment from receiving it. The aspect of social responsibility in patient-care quality and efficiency is to minimize the length of stay for patients to provide access for more patients, and thus otherwise may steer the capacity constraints.

Justification of Necessary Changes to the Organization

As medical continue to be a major catastrophe in various health care centers, organizational behavior management (OBM) should be set to focus on what the people should do, examine why they should do it, and eventually apply the evidence-based intervention approach to advance what people do (Frederiksen, & Johnson, 1981). As affirmed by Frederiksen, & Johnson (1981), the OBM sets a pragmatic approach for laying out a significant element of every defective health care system behavior. It is regarded that behavior is influenced by the organizational system in which it happens, yet it may be handled as a distinct contributor to various medical errors, and some adjustments in behavior can avoid the medical mistake. Healthcare error is an issue in the procedure of care itself or catastrophe of a strategic action to be accomplished resulting to injury to a patient, and the latter prevention-focused description best fits the use and application of organizational behavior management (OBM).




Frederiksen, L. W., & Johnson, R. P. (1981). Organizational behavior management. In Progress in             behavior modification (Vol. 12, pp. 67-118). Elsevier.

Rosswurm, M. A., & Larrabee, J. H. (1999). A Model for Change to Evidence‐Based Practice.     Journal of Nursing Scholarship, 31(4), 317-322.

Rothschild, J. M., Landrigan, C. P., Cronin, J. W., Kaushal, R., Lockley, S. W., Burdick, E., … &             Bates, D. W. (2005). The Critical Care Safety Study: The incidence and nature of adverse             events and serious medical errors in intensive care. Critical care medicine, 33(8), 1694-    1700.

Scott, T., Mannion, R., Davies, H., & Marshall, M. (2003). The quantitative measurement of             organizational culture in health care: a review of the available instruments. Health services             research, 38(3), 923-945.