Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample

Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample

The Institute of Medicine’s publication “To Err Is Human” encapsulated its recommendation that human medical errors can be avoided by identifying and designing processes that make it difficult for health practitioners to commit errors and easy for them to make the right clinical judgments (Donaldson et al., 2000). Equally, the corresponding report, i.e., Crossing the Quality Chasm (Baker, 2001), summarized its purpose of highlighting the lack of consistency and high-quality based on scientific knowledge to meet patient’s needs. In sum, these reports highlighted the frequent causes of harm in healthcare and addressed the need to improve quality and patient outcomes by minimizing errors. This memo highlights and discusses these reports’ influence on Mt. Sinai Hospital and its patient safety and security events and mitigating frameworks.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

The Influence of IOM Reports’ Objectives and Impacts on the Goals, Mission, and Values of Mt. Sinai Hospital

Mission and Goal

            Mt. Sinai hospital’s mission of providing compassionate care delivery through seamless collaboration and advancing medicine in the many diverse communities it serves through unparalleled training, research, and outreach (Mount Sinai Health System, n.d.). The mission aligns with the fundamentals set by Donaldson et al. (2000), who describe layout actions that the internal and external players in the healthcare industry may take to improve the delivery system’s commitment to patient safety concerns. The reports also influence the hospital’s goals of consistent growth and challenge to the existing conventions, consistent scientific advancements, competent leadership, and a cooperative approach in patient care delivery (Mount Sinai Health System, n.d.).(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Furthermore, the study also outlines a series of steps that the healthcare delivery system should take to promote patient safety (Donaldson et al., 2000). These recommendations include establishing a national emphasis on patient safety, making more knowledge accessible, establishing patient safety standards, and defining how healthcare organizations can implement safety programs.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Values: Creativity, Agility, Teamwork, and Empathy

Correspondingly, the follow-up report by Baker et al. (2001) focused on how the health system can be reinvented to promote creativity and enhance care delivery. In the report, healthcare stakeholders, including health providers, government officials, partners, and users of healthcare services and products, must collaborate on healthcare in achieving universal care needs (Baker, 2001). These reports influence the goals and values that the Mount Sinai Hospital has set in place to achieve its aim of providing compassionate care.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Mt. Sinai hospital’s other values include safety, agility, teamwork, and empathy. Therefore, the reports support the hospital’s initiative to establish patient safety and security by identifying and developing forward-thinking approaches to challenge patient security and safety. Similarly, the value for creativity through the identification and development of forward-thinking policies questions contemporary patient safety, and the reports support security issues. Moreover, the reports support Mt. Sinai hospital’s value for agility, i.e., its ability to be flexible and quick to adapt to changes; teamwork, i.e., the need to work together in diverse teams to achieve superior outcomes; empathy, i.e., the need to demonstrate a deeper understanding on patients and their families through compassion, inclusion, respect, and care.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Adverse Safety Event That Led To Systems Changes Related To Patient Safety at Mt. Sinai Hospitals  

Heart Attack and Prolonged Admission Time

Despite its reputation and image as one of the best healthcare provider in the USA, Mt. Sinai Hospitals have once been exposed to staffing shortages despite the high patient volumes leading to serious patient safety issues in its emergency department, which has once been termed a war zone (Bean, 2019). Staffing shortages at Mt Sinai Hospital have led to the facility’s inability to control infection and maintain patient safety, which is its core value. The New York Post’s revealed that former physicians and nurses at the hospital’s emergency department pointed out lapses in care to an extent some patients could have a heart attack without clinicians noticing or were not admitted to critical care due to lack of space.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

It was believed that the hospital’s switch to split flow ED operations in 2016 could have contributed to the adverse events that as aimed at expediting care and lowering wait times but instead created a dangerous workload of patients due to staffing and bed shortage (Bowden, 2019). These concerns drove the hospital’s leadership to add additional nurses, a nurse manager, assistant nurse managers, and other additional 130 employees in the ED. The hospital moved to renovate the ED, observation unit and double the number of treatment locations.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

In its statement, the hospital administration reiterated its commitment to the pursuit of excellence through a strategic review in 2016. Following the review, the hospital’s mission has achieved higher survival rates among patients admitted with chronic diseases (Mount Sinai Health System, 2019). Besides, the hospital’s management opened an express care facility to alleviate crowding at its emergency department. Further, the hospital is committed to serving a diverse community facilitating their safety, care, and accessibility to the health services.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Effect of the Adverse Event on Operational Procedures at Mt. Sinai Hospital.

Heart attack events and lack of quick admission into critical care have been attributed to short staffing at Mt. Sinai Hospital. According to Babaei & Taleghani (2019), obstacles to high-quality care include a shortage of nursing personnel and a lack of time to care. Nursing, in this sense, is a crucial factor in assessing a hospital’s care quality and the nature of patient outcomes.  On an abstract level, there is widespread agreement that nurses are critical to the healthcare delivery system and that nurse staffing affects patient safety. As a result, paying attention to nurses’ wishes and demands would lead to nurses becoming mindful of their needs.

Furthermore, staffing ratios influenced infection control, patient safety, patient boarding, and the ED conditions, which went against a first-class medical center (Bowden, 2019). The management system could inevitably cause more incidents related to patient safety. However, the management’s extraordinary efforts to salvage the situation led to an increase in staff number. The system in place, i.e., the split flow ED operations, could achieve its potential. With this system, every patient seeking medication goes straight to ER room regardless of their condition. Therefore, patients can wait to see a doctor in approximately 30 minutes, which initially overloaded employees given previous staffing levels and lack of beds.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Patient Safety Goals, Mission, Purpose, and Values at Mt. Sinai Hospitals

Patient safety is a critical pillar at Mt. Sinai Hospital. The hospital goals directly touching on patient safety include the hospital’s pursuit for scientific advancement and collaborative approach in providing exceptional patient care.  Institute of Medicine’s (IOM) study “To Err is Human” recommended that new technologies be developed and tested to minimize medical errors. The subsequent study, “crossing the quality chasm,” released in 2001, argued that the use of information technology is a critical step in reforming and changing the healthcare system so that more, leading to safer care.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Mt. Sinai places a high value on innovation as a means of advancing medical science. Clinical decision support, for example, offers guidance and patient-specific information to health care professionals. This information is filtered and conveyed to the clinical personnel at the right times to help them make better decisions (Alotaibi & Federico, 2017). As a result, health information technology aims to increase patient safety by reducing medication mistakes, adverse drug reactions, and adherence to practice guidelines.

Medical errors may occur when there is a lack of communication. Such error can cause a widespread problem in today’s healthcare settings (O’Daniel & Rosenstein, 2008). Collaboration is also essential because it allows professionals to play complementary roles and work together cooperatively to solve problems, make decisions, and devise and carry out patient care plans (O’Daniel & Rosenstein, 2008). Furthermore, effective communication enhances nurse’s agility, which Mt. Sinai Hospital’s core operating value, due to efficient coordination of workplace activities.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

The operating value of Mt. Sinai Hospitals is teamwork. Therefore, Mt. Sinai’s collaborative approach to patient care is crucial to patient security and safety. Therefore, the hospital’s mission of providing compassionate care by advancing medicine through education, research, and outreach with the community it serves is significant to achieving patient safety and security. According to Babaei & Taleghani (2019), compassion is a characteristic of quality care and a substantial patient-centered nursing component. Carayon & Gurses (2008) argue that short staffing can reduce inpatient length of stay. Compassion is a significant Mt. Sinai operating value. Compassion leads to safer care as nurses are more concerned with the patient’s wellbeing, thus helping patients get faster recovery, manage their pain, and shorter hospital stays.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Clinical/Medical Risks and Medical Staff as Second Victims

Patient falls, cardiac arrest, and prolonged recovery time

 The medical errors associated with short staffing include patient falls, cardiac arrests, and prolonged recovery time. Overworked nurses can experience exhaustion or burnout, impairing their ability to concentrate on tasks. Exhaustion coupled with poor nurse-to-patient ratios has been associated with a rise in falls, a higher risk of infection, and nurse errors (Garrett, 2008). Injury and even death are real consequences of understaffing (Staggs & Dunton, 2014). Medical mistakes, a lack of engagement, and missing nursing care may result from this lack of focus. Lack of engagement can lead to patients being taken care of differently and an increased fall for those who need help moving around or bed adjustment.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Negative emotional and psychological health

When a clinical setting is understaffed, the workload is spread to a few caregivers expected to work longer hours (Carayon & Gurses, 2008). As a result, nurse’s psychosocial and emotional health is affected. In this circumstance, nurses are unable to function, further contributing to a staffing shortage. This is because nurses are constantly under stress, thus, develops anxiety and depression, as well as other stress-related illnesses.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Strategies to Mitigate Medical Errors

Training Nurses

Medical professionals often encounter feelings of self-doubt, humiliation, frustration, inadequacy, and anxiety due to medical errors (White & Gallagher, 2011). Hospital facilities should participate in medical error prevention, and healthcare organizations should concentrate on retaining nurses by providing a supportive workplace culture. Healthcare organizations should create flexible working schedules to avoid fatigue among employees.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Effective medical systems

Mt. Sinai Hospital management support caregivers by introducing the split flow ED operation in which reporting patients are classified depending on the complexity of their condition, understanding, and stability. Secondly, the hospital should increase technical support and additional resources, e.g., advanced health systems and increased operation units to help manage patients. The inclusion of nurses is crucial since they provide care and safeguard the wellbeing of patients.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Evaluate the Statement “those who make errors that harm patients are themselves, victims.”

Medical errors affect caregivers just as it affects patients and their families. Even when clinically expected, health care providers are repeatedly subjected to the emotional distress caused by death resulting from medical errors (Grissinger, 2014). Known as the second victims, caregivers are often exposed to clinical situations, causing psychological trauma to cause adverse events while providing care (Grissinger, 2014). Despite the improved reporting and transparency of medical errors, second victims are not supported in their greatest time of need. The impact of the mistakes is felt in their private, social, and professional. Grissinger (2014) argues that the second victims suffer from illnesses that require immediate attention, such as hypertension, and post-traumatic stress disorder (PTSD), thus poor health status.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

The Influence of the IOM Report’s Objectives and Impacts on the Goals, Mission, and Values of Mt. Sinai Hospital

The objective and the impacts of the Institute of Medicine’s (IOM) report “To err is human” and “crossing the quality chiasm” continue to have a significant influence in the healthcare sector. The two reports argued for the use and advancement in technology to mitigate against medical errors and secure patient safety and security in health care settings. Rodziewics et al. (2021) argue that there is a need for advancement in medical practice to limit medical errors, particularly in minimizing errors resulting from medical interventions and negligence. The need for advancement in technology is a crucial goal of Mt. Sinai Hospitals. Equally, the need for creativity is an essential value for the Mt. Sinai Hospitals. The reports are crucial in guiding the hospital to provide unraveled care through scientific advancement. For instance, information technology such as electronic health records is essential in reducing the patient backlog and increasing admission rates to patients and the Mt. Sinai Hospitals. (Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample) 

According to Rodziewicz, & Hipskind (2018), medical errors due to omitted clinical actions or wrong actions taken. Bypassing or taking improper clinical action are partly caused by increase increased workload and staff fatigue. These patient harms occurring during healthcare increases morbidity and mortality. The two reports also argue for adequate staffing as a critical facet of patient care. In response to the complaints on nursing staff crisis, late admission, and patients’ deaths, Mt. Sinai Hospital increased nursing staff, expanded clinical units, and supported the use of split flow ED associated with favorable patient outcomes. Therefore, healthcare organizations’ safety systems seek to prevent harm to patients, their families, and friends.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

References

Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi medical journal, 38(12), 1173.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample) 10.15537/smj.2017.12.20631  

American Nurses Association. (n.d.). Nurse Staffing. Retrieved March 29, 2021, from(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample) https://www.nursingworld.org/practice-policy/nurse-staffing/

Babaei, S., & Taleghani, F. (2019). Compassionate care challenges and barriers in clinical nurses: A qualitative study. Iranian journal of nursing and midwifery research, 24(3), 213(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample). 10.4103/ijnmr.IJNMR_100_18

Baker, A. (2001). Crossing the quality chasm: a new health system for the 21st century (Vol. 323, No. 7322, p. 1192). British Medical Journal Publishing Group.

Baker, A. (2001). Crossing the quality chasm: a new health system for the 21st century (Vol. 323, No. 7322, p. 1192). British Medical Journal Publishing Group.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Bean, M., 2019. Mount Sinai’s ED is a ‘war zone,’ the nurse says. [Online] Beckershospitalreview.com. Available at: https://www.beckershospitalreview.com/quality/mount-sinai-s-ed-is-a-war-zone-nurse-says.html  [Accessed 28 March 2021].(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)

Bowden, E. (2019). Mount Sinai Hospital emergency department is a ‘war zone,’ workers say. New York Post. Retrieved March 28, 2021, from https://nypost.com/2019/12/09/mount-sinai-hospitals-emergency-department-is-a-war-zone-workers-say/.

Carayon, P., & Gurses A.P. (2008). Nursing Workload and Patient Safety—A Human Factors Engineering Perspective. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); Chapter 30. Available from(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample): https://www.ncbi.nlm.nih.gov/books/NBK2657/

Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: building a safer health system. https://doi.0.17226/9728

Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. AORN Journal, 87(6), 1191-1204. https://doi.org/10.1016/j.aorn.2008.01.022

Grissinger, M. (2014). Too many abandon the “second victims” of medical errors. Pharmacy and Therapeutics, 39(9), 591. (Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159062/#b4-ptj3909591

https://www.mountsinai.org/about/mission

Mount Sinai Health System. (2019).Statement: The Mount Sinai Hospital Emergency Department. Retrieved March 28, 2021, from https://www.mountsinai.org/about/newsroom/2019/statement-the-mount-sinai-hospital-emergency-department.

Mount Sinai Health System. (n.d.).Our Mission. Retrieved March 28, 2021, from https://www.mountsinai.org/about/mission.

O’Daniel, M., & Rosenstein, A.H. (2008) Professional Communication and Team Collaboration. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); Chapter 33. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2637/

Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., … & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, 366. https://doi.org/10.1136/bmj.l4185

Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. [Updated 2021 January 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: (Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample)https://www.ncbi.nlm.nih.gov/books/NBK499956/

Rodziewicz, T. L., & Hipskind, J. E. (2018). Medical error prevention. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Skeptical Scalpel. (2019, September 18). The third leading cause of death revisited. Physician’s Weekly(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample).https://www.physiciansweekly.com/third-leading-cause-of-death-revisited/

Staggs, V. S., & Dunton, N. (2014). Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing. International Journal for Quality in Health Care, 26(1), 87-92.(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample) 10.1093/intqhc/mzt080

White, A. A., & Gallagher, T. H. (2011). After the apology: Coping and recovery after errors. AMA Journal of Ethics, 13(9), 593-600(Executive Board Memo on Organizational Safety and Quality Comprehensive Nursing Paper Sample). https://doi.10.1001/virtualmentor.2011.13.9.ccas1-1109