BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure BHA-FPX4004 Patient Safety and Quality Improvement in Health Care Part One: Risk Management Policy and Procedure Purpose Statement

The purpose of this policy and procedure is to create a safe environment for both our patients and employees by:

1. Risk Elimination, Reduction, and Management: Identifying, reducing, and managing threats and vulnerabilities to patients, as well as to the hospital’s information systems and applications.

2. Optimizing Care Delivery: Maximizing opportunities for delivering optimal care while minimizing adverse events.

3. Enhancing Patient Safety: Identifying, resolving, and preventing potential risks throughout the hospital’s departments, with a central focus on patient safety and care.

Definitions

• Risk Prevention: Precautionary measures taken to eliminate foreseeable risks (Hofmann & Scordis, 2018). Example: Quarterly and annual reviews of Hospital Emergency Procedure manuals.

• Risk Reduction: Decreasing the likelihood of risk occurrence (Hofmann & Scordis, 2018). Example: Mandating proper hand hygiene to reduce hospital-acquired infections.

• Regulatory Compliance: Adherence to policies, laws, or recommendations for appropriate healthcare guidelines and operational practices (Dückers et al., 2009). Example: Complying with The Joint Commission’s patient safety procedure for proper patient identification.

• Patient Safety: Initiatives and protections in healthcare aimed at preventing adverse harms to patients (Dückers et al., 2009). Example: Ensuring all bed rails are in the upright position to protect patients from falls.

• Adverse Event: Incidents resulting in harm to a patient, hospital employee, or visitor. Example: A patient slipping and falling due to a wet spot on the floor (Dückers et al., 2009).

• Near Miss: A prevented harm that could have resulted in unnecessary injury to a patient, employee, or visitor (Dückers et al., 2009). Example: A nurse noticing a discrepancy in patient information before administering medication.

Risk Categories and Identification Techniques

• Legal and Regulatory Compliance: Measures taken to adhere to healthcare policies and laws (Lee, Chang, & McCombs, 2019). Example: Compliance with the federal 340B Drug program.

• Clinical and Patient Safety: Focus on patient safety initiatives and reducing patient fall rates (Nedved et al., 2012).

• Technology Integrations: Implementing preventive measures to protect against cyberattacks (Ayatollahi & Shagerdi, 2017).

• Infectious Disease Preparedness: Strategies to protect employees and patients from infectious diseases (Rebmann, Carrico, & English, 2007).

Risk Management Strategies

• Employee Education: Annual training modules on risk management strategies.

• Documentation: Complete and accurate documentation of all risk occurrences.

• Departmental Preparedness: Promoting departmental cohesiveness on best practices.

• Patient Concerns: Investigating and resolving patient concerns.

• Participation in Surveys: Engaging in state, federal, or regulatory surveys (Ayatollahi & Shagerdi, 2017).

Risk Categories

• Cybersecurity: Protecting patient health information and hospital data (Ayatollahi & Shagerdi, 2017).

• Health Information Management (HIM): Managing compliance and preventing coding vulnerabilities (Scott, 2015).

• Billing and Collections: Ensuring error-free billing to avoid claim denials (Scott, 2015).

Risk Manager Role

The Risk Manager is responsible for implementing programs and policies to identify, evaluate, and prevent risks throughout the hospital system (Seckel, 2013).

Part Two: Application of Risk Management Principles

The potential risk being analyzed is Patient Identification Errors. These errors can disrupt patient care and lead to unnecessary harm (Clancy, 2005).

Risk Identification

Strategies for identifying patient identification errors include conducting hospital-wide audits and providing education for frontline staff (Thomas & Evans, 2004).