Please follow instructions downloaded“Drawing on a safety event from practice, analyse the evidence...

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Please follow instructions downloaded“Drawing on a safety event from practice, analyse the evidence base of patient safety factors, inherent in health care systems.”  2500 words +/- 10% leeway  The report will analyse a safety event from practice. The safety event may be an error, a near miss, an adverse event, a never event or an example of poor practice that caused harm to a patient or had the potential to cause harm.  You will need to complete a summary of events log (a factual account of what happened) which should be included as an appendix. The report should include:  1. a background that explores some of the key clinical governance and patient safety literature, that refers to your professional code of conduct, regulatory bodies and relevant reviews. 1. discussion of the safety event, including what type of error was demonstrated, what factors did or could have contributed to the safety event happening, for example, if you choose to write about the occurrence of a pressure ulcer on a patient's sacrum, while they are in hospital, you could explore the risk assessment tools used to prevent this from happening and the literature around the topic.  1. discussion of the wider factors that could have influenced the event happening, for example, individual, team, organisational or cultural barriers.  1. If you are exploring a near miss, these factors may have been enablers - that is perhaps individual, team organisational or cultural factors enabled or helped the near miss to be spotted and for harm to the patient to be averted.  The report should be written in the third person.  A template for capturing the safety event has been created specifically for this assessment. This is similar to an incident report and should be used to distil the main points. The purpose of the summary of the events is to provide context for the reader and to help you to unpick the event in more detail. It also allows you to complete a form similar to a datix report, which you may not have done previously. The summary of the event log should be an objective and factual account of what happened during and after the event.  Please ensure that you maintain confidentiality throughout the report. You can choose what situation/scenario you write your report on - this is to keep the assessment real to practice, as health professionals often have to respond to an investigation and write a report days/weeks or months after an event from the notes that they had written when delivering the care.   Summary of safety event template 	Setting Please do not use names of people, places or organisations in this form to maintain confidentiality. Use a generic description e.g. acute ward, psychiatric intensive care unit, recovery, theatre, corridor, patient’s home, A&E, ambulance, nursing home, XR department, clinic etc. 	 	Time of day (approximately). 	 	Summary of the safety event. Write what happened here, objectively. Please do not include names or locations.  	 	Actions taken by the person or people involved. 	 	How was the patient informed of the safety event?  	 	Key stakeholders. Identify the type of stakeholders involved here e.g. patient, ODP, relative, nurse, junior doctor, senior doctor, physiotherapist etc. 	 	Outcome. What happened after the safety event?

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WRITTEN ASSIGNMENT		2
WRITTEN ASSIGNMENT
Table of contents
Introduction	3
Background	3
Discussion	4
Implications	5
Recommendations	6
Conclusion	8
References	10
Introduction
Medical mistakes pose a peril to healthcare institutions in the United Kingdom healthcare system. These avoidable medical mistakes have resulted in thousands of fatalities and billions of dollars in losses. Ongoing studies estimate that because of these avoidable medical mistakes, 100,000 individuals bite the duct every year, and somewhere north of 9 billion UK Currency is lost. The loss demonstrates how much cash the healthcare industry loses as a result of mistakes like using unfortunate language in hospital facilities, office technology that breaks down, and perhaps even an unfortunate safety culture. Since a close-to-miss is an unforeseen occurrence that has the possibility to harm or harm a facility without necessarily resulting in human injury, obviously, medical errors are a regular cause of close-to-misses in healthcare facilities. Some unacceptable medications can have various negative repercussions, including the possibility of a patient's stay in the hospital being drawn out, a likely rise in hospital costs, an increase in patient deaths, distrust, and serious harm. In this essay, we'll take a gander at a speculative situation, including a woman who visited a nearby hospital to get some prescriptions and the subsequent close call.
Background
Medical mistakes are a severe hazard to patient safety and a public health issue. Due to the potential vulnerability of every patient, medical mistakes are expensive from a human, financial, and societal perspective (Nurdin & Wibowo, 2021). The purpose of the current report is to provide an overview of the issue Using the published literature, but it also emphasizes the significance of Using standard terminology and classifications, which are essential resources for researchers in order to develop accurate and reliable methods for error detection and reporting. In actuality, agreement on common terminology permits the comparison of data in many situations. Errors can be categorized based on their results, the environment in which they occur, the type of operation involved, or the likelihood that they will occur. The reporting of incidents and the recording of near-misses are seen as valuable sources of knowledge, and the process analysis tools Healthcare Failure Mode Effect Analysis and Root Cause Analysis (RCA) are highly effective. Additionally, strategies for improving patient safety are taken into account within the larger framework of clinical risk management. The goal of new techniques in the field of medical mistakes is to reduce the recurrence of patterns that may be avoided and are linked to greater error rates. The many methods for identifying medical errors are taken into account while analyzing error categories, as well as their prevalence, avoidance, and associated variables. The genuine architectural design of a hospital facility, including its technology and equipment, and its effect on patient safety, has as of late stood out in the medical field. Basic adjustments must be made to how healthcare is given, as well as to culture and the physical climate, to address the problems of medical mistakes and significant safety issues (Hall, Johnson, Watt & O’Connor, 2019). This will empower caregivers and the resources that support them to give safe treatment. Despite yearly investments of billions of dollars in healthcare facilities, the impact of the hospital's equipment and technology on patient quality and safety has not previously been considered. This is an intriguing opportunity to Use new and existing research to improve the functioning conditions for nurses and other healthcare professionals, eventually prompting improved results for both nurses and patients. The somewhat more established woman visited a nearby medical center, where she was recognized as having intense renal harm and uncontrolled hypertension. Her medical history was somewhat troublesome because she had been diagnosed with coronary vein disease and hypertension. She was smoking before she went, and since her relatives have passed away, she is under stress. When the woman was released, the overall specialist suggested 50 mg of metoprolol two times a day, 30 mg of torsemide day to day, 10 mg of amlodipine two times a day, and 2 mg of doxazosin every day. These medications were planned to improve the woman's health state. Despite having a prescription, the woman wound up taking the antipsychotic medication Navane while she was expected to take Norvasc. This was a problem with dispensation. This was an instance of a drug blunder, and as a result, the woman was influenced today, 90 days subsequent to starting the medicine, by the highest degree of exhaustion and sluggish movements. When the woman got back to the hospital, she was given an uneasiness and depression diagnosis. For her new infirmity, the specialist suggested citalopram and alprazolam for her new infirmity. She was distressed by the wrong medication she was taking and was rushed to the trauma center, where it was determined that she had thiothixene-related drug-induced Parkinsonism. Subsequent to stopping the Use of thiothixene, she, in the long run, recuperated.
Discussion
In the woman's case, the processes that prompted the close miss included: faults in dispensation; this issue might have resulted from the pharmacist's failure to deal with the prescribed medicine appropriately.

“Drawing on a safety event from practice, analyse the evidence base of patient safety factors, inherent in health care systems.” 2500 words +/- 10% leeway The report will analyse a safety event from...

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