1. Describe a healthcare_related situation prompting a patient safety concern (S). 2. Analyze background information about the concern by doing the following.
A. Discuss a healthcare safety concern using the BAR (situation, background, assessment, recommendation) format by doing the following:
1. Describe a healthcare-related situation prompting a patient safety concern (S).
2. Analyze background information about the concern by doing the following (B):
a. Describe the data that support or would support the need for change.
b. Explain how one or more national patient safety standards apply to this situation.
3. Discuss the impact of the safety concern on the patient(s), staff, and organization (A).
a. Explain how the safety concern affects value for the patient(s) and the organization.
4. Recommend an evidence-based practice change that addresses the safety concern (R).
a. Discuss how this recommendation aligns with the principles of a high reliability organization.
b. Describe two potential barriers to the recommended practice change.
c. Identify two potential interventions to minimize the barriers from part A4b to the recommended practice change.
d. Discuss the significance of shared decision-making in implementing this recommendation.
e. Describe an outcome measure that could be used to evaluate the results of the recommendation.
f. Discuss how the care delivery model in this organization would be impacted by this change.
B. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
Objectives To investigate what healthcare professionals perceived and experienced as key patient safety concerns in Bhutan’s healthcare system.
Design Qualitative exploratory descriptive inquiry.
Settings Three different levels of hospitals, a training institute and the Ministry of Health, Bhutan.
Participants In total, 140 healthcare professionals and managers.
Methods Narrative data were collected via conversational in-depth interviews and Nominal Group Meetings. All data were subsequently analysed using thematic analysis strategies.
Results The data revealed that medication errors, healthcare-associated infections, diagnostic errors, surgical errors and postoperative complications, laboratory/blood testing errors, falls, patient identification and communication errors were perceived as common patient safety concerns. Human and system factors were identified as contributing to these concerns. Instituting clinical governance, developing and improving the physical infrastructure of hospitals, providing necessary human resources, ensuring staff receive patient safety education and promoting ‘good’ communication and information systems were, in turn, all identified as processes and strategies critical to improving patient safety in the Bhutanese healthcare system.
Conclusion Patient safety concerns described by participants in this study were commensurate with those identified in other low and middle-income countries. In order to redress these concerns, the findings of this study suggest that in the Bhutanese context patient safety needs to be conceptualised and prioritised.
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