Write a 5-7 page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue that occurred. Include an explanation of why it is important to address the issue and the role the patient safety officer will play in helping to resolve the issue.

Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. “Quality and patient safety in health care have been on the forefront of the public’s mind since the publication of the Institute of Medicine’s (IOM) seminal report, ‘To Err Is Human,’ in 1999” (Johnson, Haskell, & Barach, 2016, pg. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.

Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall. 

For this first assessment, you will assume the role of a patient safety officer at your local hospital. You will analyze a patient safety issue that occurred and then prepare a five- to seven-page recommendation for senior leaders about why it is important to address the issue, along with your recommendations about how to address it. You will also need to detail the role you as the patient safety officer will play in helping the organization resolve the issue. 

Reference

Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016). Case studies in patient safety. Burlington, MA: Jones & Bartlett Learning.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: 

• Competency 1: Analyze the quality and performance improvement activities within the health care organization.

  Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.

• Competency 3: Analyze the importance of patient safety in health care.

  Apply the health care safety imperative to a patient safety issue.
  Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.
  Analyze regulatory agencies’ role and impact on organizations’ patient safety programs.

• Competency 4: Apply leadership strategies to quality improvement in a health care organization.

  Analyze the patient safety officer’s role in implementing patient safety plans.

• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.

  Write a clear, persuasive, organized recommendation plan that is generally free of errors and is reflective of professional communication in the health care field.
  Provide citations and title and reference pages that conform to APA style and format.

Preparation

To help prepare for successfully completing this assessment:

• From  the Vila Health: Patient Safety simulation activity that interests you the most for further analysis in your assessment:

  HIPAA/Privacy Violation.

Instructions

For the scenario you selected, write a five- to seven-page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of these headings in your paper and to address all of the bullets underneath each heading:

• Potential threat to patient safety:

  Identify the issue you selected from the simulation activity as the potential safety threat.
  Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.

• Implications of not addressing threat:

  Evaluate the risk to the organization if this issue is not addressed. In your evaluation, be sure to address all of the following:

  What does the health care safety imperative say about the issue?
  How does the health care safety imperative apply in this case?
  Which regulatory agency(ies) have oversight about the issue?
  What specifically do the regulation(s) state about the issue? For example, you might consider the Joint Commission’s national patient safety goals. 
  What impact do regulatory agencies have on organizations’ patient safety programs? 
  How do health care organizations incorporate regulatory agencies’ guidance when establishing reporting and investigation best practices?
  If the hospital fails to correct the threat, what are the potential consequences to patients, employees, and to the organization?

• Patient safety officer’s role in effective implementation of patient safety plans:

  Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.  
  Clarify your responsibility and role as the patient safety officer in this specific instance.
  Provide one example from the literature to illustrate your points. 

• Recommendations to reduce patient safety threat:

  Describe your five-point plan to reduce or eliminate this patient safety threat.

  What best practice tools or techniques does your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.   

In a health care professional setting, recommendations to leadership would typically not be in APA format. As a result, your paper does not need to conform to APA format and style guidelines. It does, however, need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing.  

Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references do need to conform to APA guidelines.

Additional Requirements

• Length: Your recommendation will be 5–7 double-spaced pages, not including title and reference pages.
• Font: Times New Roman, 12-point.
• APA Format: Your title and reference pages need to conform to APA format and style guidelines. The body of your paper does not need to conform to APA guidelines. Do make sure that it is clear, persuasive, organized, and well written, without grammatical, punctuation, or spelling errors. You also must cite your sources according to APA guidelines.
• Scoring Guide: Please review this assessment’s scoring guide to ensure you understand how your faculty member will evaluate your work.

HIPAA

The day after the medication error, B. Moore’s mother signs in at the front desk to get her visitation pass. As she is standing at the front desk, she overhears an inappropriate conversation between Ida Feeney, the unit secretary, and a nurse from a different unit of the hospital.

Ida Feeney and Brenda Turner

Ida Feeney: Did you hear about the Moore kid? It’s a good thing they caught that right away. She’s small for her age, and that insulin could have really done a number on her.

Brenda Turner: Jeez, how much did they give her?

Ida Feeney: Well, she wasn’t supposed to have any. But I forget the actual dose. I’ll look in the EHR later, but I think it was pretty high.

Brenda Turner: Wait, is it Belinda Moore?

Ida Feeney: Yes, why?

Brenda Turner: I think she’s in a gymnastics class with my daughters!

Now that you have observed this inappropriate conversation, answer the following questions about HIPAA regulations.

Question 1: Which regulatory agency is responsible for overseeing the HIPAA privacy and security rule?

Your response:

This question has not been answered yet.

Incorrect.

Correct Answer: U.S Department of Health and Human Services.

The Joint Commission is an independent regulatory agency. It is not part of the U.S. government, and it does not have the authority or responsibility to enforce privacy and security rules.

Incorrect.

Correct Answer: U.S Department of Health and Human Services.

While the DEA is a U.S. government regulatory agency, its purpose is not to oversee the HIPAA privacy and security rules. Its primary responsibility is to enforce controlled substances laws.

Correct!

The U.S Department of Health and Human Services Office of Civil Rights is responsible for enforcing the HIPAA privacy and security rules.

Incorrect.

Correct Answer: U.S Department of Health and Human Services.

While CLIA is a U.S. government regulatory body, its purpose is not to enforce the HIPAA privacy and security rules. CLIA’s purpose is to ensure laboratory testing quality.

Question 2: How would the health care organization’s privacy officer determine whether others who were not involved in the patient’s care had viewed her medical record?

Your response:
This question has not been answered yet.

Expert Response: Health care experts on the HIPAA privacy and security rules indicate the best way to determine whether a patient’s medical record was accessed inappropriately is to conduct file audits. These audits may include, but are not limited to:

· Random file reviews to determine who has recently accessed a patient’s medical record and if this access was warranted.

· Reviews of business associate contracts.

· Audits of disclosures in accordance with the privacy notice, along with the organization’s adherence to confidential communications protocols.

Question 3: Health care experts on the HIPAA privacy and security rules indicate the following as the most appropriate sequence to follow in addressing the potential HIPAA violation.

1. Meet with B. Moore’s mother to document the details of her complaint.

2. Inform risk manager of the potential violation.

3. Audit B. Moore’s medical record to determine who has accessed it during her stay.

4. Interview involved employees.

5. Determine whether any discipline is warranted.

6. Educate staff about the HIPAA rule.

Your response:
This question has not been answered yet.
Correct!

Investigations collect as much information as possible. Information and data collected in the investigation will help the privacy officer to determine whether an actual breach occurred, ensure that all aspects of the complaint have been examined, and minimize risks to the organization and the patient.

Incorrect.

Correct Answer: True

Investigations collect as much information as possible. Information and data collected in the investigation will help the privacy officer to determine whether an actual breach occurred, ensure that all aspects of the complaint have been examined, and minimize risks to the organization and the patient.

Question 4: Identify the most common penalties employees may face if they are found in violation of HIPAA.

Your response:
This question has not been answered yet.

Expert Response: Health care experts on the HIPAA privacy and security rules indicate that failure to comply with HIPAA may result in civil and criminal penalties. Violations of the law include those that are unknowing, reasonable cause, or willful neglect — both corrected and uncorrected. The most common penalties employees face when they are found to have violated HIPAA rules include:

· Monetary penalties ranging from $100 to $1.5 million.

· Prison sentences up to 10 years.

· Disciplinary action, up to and including termination.

Question 5: How would a privacy officer determine whether this is an isolated event or a trending issue? Why is this an important part of the investigation?

Your response:
This question has not been answered yet.

Expert Response: Health care experts on the HIPAA privacy and security rules recommended these best practices to determine whether potential HIPAA violations are isolated events or trending issues:

· Conduct random audits to determine whether this employee or others have been accessing the medical records of patients who are not under their care.

· Perform reviews of patient and family complaints.

Determining whether HIPAA violations are isolated events or trending issues is an important part of this investigation, because this information will reveal whether the health care organization needs to implement tighter security procedures. Likewise, it may need to do more to educate staff about HIPAA security rules. If the organization fails to take action to reduce the number of these events that occur, it could be subject to fines and penalties.

Question 6: Health care organizations may disclose patients’ medical information without their permission in all of following situations EXCEPT:

Your response:
This question has not been answered yet.
Incorrect.

Correct Answer: In facility directories.

A health care facility may disclose patient medical information directly to the patient once it has confirmed the patient’s identity.

Correct!

A health care facility must obtain the patient’s permission to publish his or her information in its directory.

Incorrect.

Correct Answer: In facility directories.

In certain circumstances, health care organizations are not required to obtain patient permission to disclose medical information. Reporting communicable diseases is one such circumstance. The reason for this is to protect the public health.

Incorrect.

Correct Answer: In facility directories.

A health care facility may disclose patient information for the purposes of payment, treatment, and operations. For example, the facility may submit claims for payment to insurance companies without the patient’s permission.

Question 7: Identify three covered entities that are subject to HIPAA compliance.

Your response:
This question has not been answered yet.

Expert Responses: Health care experts on the HIPAA privacy and security rules indicate the following as covered entities subject to HIPAA compliance:

· Health plans.

· Health providers.

· Business associates.

·

Health care clearinghouse