DHA 715 Week 2 Clinical Risk and Patient Safety Analysis Example

One Admission in Four: Measuring and Reducing Clinical Risk in Four Rural Hospitals After a Wrong-Site Surgery

[Student Name]

University of Phoenix

DHA/715: Risk Management in Complex Health Organizations

Week 2 Assignment

[Instructor Name]

[Date]

The rural hospitals, events, record review results, staffing data and safety program are composites written for a model paper; research findings come from the sources cited.

The wrong-site knee surgery at one of the network's rural hospitals became the starting point for a broader question. The investigation found that the operative site had not been marked, the surgical time-out was rushed because the operating room was forty minutes behind schedule and the consent form used an abbreviation that could be read as either knee. The regional vice president asked how much harm was occurring that no one had noticed. This paper examines clinical risk and patient safety across the four rural hospitals.

The Limits of Incident Reports

Incident reports are the usual way hospitals learn about harm, but they capture only a fraction of events. Staff report what they notice and feel safe reporting; many adverse drug events, infections and delayed diagnoses go unreported. In the previous year, the four hospitals received 412 incident reports, most describing falls and near misses rather than harm.

Finding Harm With Record Review

To see the true picture, the region's quality team reviewed a random sample of 240 admissions using a trigger tool, which flags clues such as reversal agents, abnormal laboratory values or unplanned transfers that prompt a closer look for harm. The review found at least one adverse event in 51 admissions, about 21%, a rate far higher than incident reports suggested.

What National Evidence Shows

The rural findings match national research. A study using trigger-based record review of 2,809 randomly selected admissions at 11 Massachusetts hospitals found at least one adverse event in 23.6% of admissions; of 978 events, 22.7% were judged preventable and 32.3% were serious or worse, and adverse drug events were the most common category at 39.0%, with surgical and procedural harm next, then harm from nursing care like falls and pressure injuries (Bates et al., 2023). Only a minority of those events had ever been captured by a voluntary report. For the rural region, the lesson is that a quiet incident log is not evidence of safety; it may simply mean staff are too busy, or too uneasy, to write reports.

Types of Harm in the Rural Hospitals

In the rural review, adverse drug events, mainly bleeding from anticoagulants and low blood sugar from insulin, made up the largest share, followed by falls with injury, pressure injuries and surgical complications. The pattern mirrors the national one, pointing the safety program toward medications first.

A Systems Model of Harm

Reason's model explains why harm occurs despite defenses. Organizations build layers of protection, like slices of Swiss cheese, but each layer has holes. Some are active failures, slips and mistakes by clinicians at the sharp end; others are latent conditions, such as staffing, schedules and design, created by decisions made far from the bedside; harm results when holes line up across layers (Reason, 2000). The wrong knee was operated on because four layers failed at once, not because one surgeon was careless.

The Wrong-Site Surgery Through the Model

The surgery passed through failed layers: no site marking at the preoperative stage, an ambiguous consent form, a time-out performed while the next patient's family waited and a surgeon and nurse who both assumed the other had checked. The latent conditions were a schedule that routinely ran late, a form designed years earlier and a culture in which nurses hesitated to stop a senior surgeon.

Staffing as a Latent Condition

The record review and incident data pointed repeatedly to staffing. Falls and medication errors clustered on shifts with vacancies and high admissions. Evidence links such conditions to death. In a study of 197,961 admissions at an academic medical center, each shift with registered nurse staffing eight or more hours below target was associated with increased mortality, a hazard ratio of 1.02 per shift; shifts with unusually heavy admissions, discharges and transfers carried a hazard ratio of 1.04 (Needleman et al., 2011). The effects look small per shift, but a patient exposed to several understaffed shifts during one stay accumulates risk, and rural units with thin rosters meet those shifts often.

Why Rural Hospitals Face Particular Risks

Rural hospitals carry specific risks: small numbers of specialists, staff covering several roles, infrequent complex procedures that reduce practice and long distances to transfer patients. A nurse who works the emergency department at night may also cover the inpatient unit, and a pharmacist may be available only by telephone after six in the evening. These conditions make layered defenses and standard processes more important, because fewer people are present to catch an error before it reaches the patient.

Program Element One: Surgical Safety

Every surgical patient's site will be marked by the surgeon before sedation, consent forms will prohibit abbreviations for laterality and the time-out will be led by the circulating nurse, with every team member stating agreement. Schedules will include buffers so time-outs are not rushed.

Program Element Two: Medication Safety

Barcode scanning will be extended to all medication administration, anticoagulant and insulin protocols will be standardized with pharmacist review and high-alert medications will require independent double checks. Remote pharmacist verification will cover the overnight hours when rural hospitals have no pharmacist on site. Because adverse drug events were the largest category in both the rural and the national reviews, this element receives the largest share of the first-year budget.

Program Element Three: Falls and Pressure Injuries

Each patient will be assessed for fall risk on admission, with hourly rounding for high-risk patients, and pressure injury prevention bundles will be applied to patients at risk. Each fall with injury will receive a brief huddle within twenty-four hours to identify the failed defense rather than the person who was present.

Program Element Four: Staffing Safeguards

The region will set minimum staffing thresholds by unit, activate float and agency support when shifts fall below them and track staffing against targets alongside harm. A shared float pool across the four hospitals, paid at a premium, will give managers a first call before closing beds or asking nurses to stay past their shifts.

Program Element Five: Speaking Up

Training will teach all staff to stop a procedure when safety is in doubt, using agreed language, and leaders will publicly support staff who do.

Measuring Safety

The program will repeat trigger-tool review of a random sample every quarter, track preventable adverse events per 100 admissions, falls with injury, hospital-acquired pressure injuries, medication events with harm and staffing below target, and report them to the regional board monthly.

Culture and Leadership

A just culture policy distinguishes human error, which is consoled, from at-risk behavior, which is coached, and reckless behavior, which is disciplined. Leaders will conduct safety rounds and share lessons from events across all four hospitals.

Conclusion

The wrong-site surgery revealed failed defenses and led to a broader discovery: adverse events in about one rural admission in five, close to national estimates of nearly one in four. The Swiss cheese model explains how defenses fail, evidence ties understaffed shifts to mortality and a layered program targets medications, surgery, falls, staffing and speaking up. Regular record review will show whether harm falls.

References

Bates, D. W., Levine, D. M., Salmasian, H., Syrowatka, A., Shahian, D. M., Lipsitz, S., Zebrowski, J. P., Myers, L. C., Logan, M. S., Roy, C. G., Iannaccone, C., Frits, M. L., Volk, L. A., Dulgarian, S., Amato, M. G., Edrees, H. H., Sato, L., Folcarelli, P., Einbinder, J. S., ... Mort, E. (2023). The safety of inpatient health care. New England Journal of Medicine, 388(2), 142-153. https://doi.org/10.1056/NEJMsa2206117

Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045. https://doi.org/10.1056/NEJMsa1001025

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768