BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

Address a Patient Safety Issue

Protecting patient safety (BHA FPX 4004 Assessment 1 Address a Patient Safety Issue) has become more important as the healthcare industry has developed. Despite most significant efforts, medical mistakes can occasionally occur, therefore it is critical to investigate these situations in order to prevent future occurrences. Two inpatients at Vila Health Medical Center’s pediatric wing had names and birth dates that were very similar.

When the nurse manager realized this, she ensured that individual notes were written in each patient’s chart and that each kid was given a different nurse. Nonetheless, the patient safety officer was concerned about the risk of error, especially given the unit’s personnel limitations. Unfortunately, a drug mixup occurred, resulting in a patient safety problem. The purpose of this assessment is to identify the underlying reason for the medication error and propose solutions to avoid such problems in the future.

Other Assessment:
BHA 4108 Assessment 3 Recommend a Strategy

Health Care Safety Imperative

Medical errors affect patient health and safety and can be caused by a variety of factors, including poor communication, insufficient training, insufficient staffing, identical patient names, and unclear medical termonologies (Rodziewicz, 2023). These errors can cause significant financial consequences for both healthcare organizations and the patients or their families. Proper documenting and reporting of these (BHA FPX 4004 Assessment 1 Address a Patient Safety Issue) incidences is critical for organizational health, as it allows for proper follow-up and remedial actions.

The Joint Commission’s National Patient Safety Goals prioritize pharmaceutical safety in healthcare. One important guideline is to double-check a patient’s name and birthdate before delivering medicine, with two people ensuring that the information matches the label (The Joint Commission, 2024). This approach assures proper patient identification and lowers the likelihood of mistakes.

Healthcare organizations must adhere to legal rules by communicating clear expectations throughout the employment process and offering continuous educational training to employees. Policies and procedures should be set to provide clear instructions to staff. Furthermore, providing an accessible secure reporting mechanism, both online and over the phone, encourages employees to report issues without fear of consequence.

Leadership is critical in fostering a culture of best practices and ensuring that patients receive the greatest possible level of medical treatment (Huang et al., 2024). Regulatory agencies define and support these best practices, establishing a standard for patient safety.


Failure to manage patient safety risks can have serious and widespread consequences for patients, healthcare professionals, and the organization. When a patient receives an improper medication or dose, the effects can be severe. These errors can result in a variety of symptoms, ranging from minor pain to serious adverse effects, depending on the medicine and the individual’s reaction (Tariq & Scherbak, 2023). Errors in prescribing or delivering medications can also cause harmful interactions between medicines, resulting in unanticipated adverse effects or reduced efficacy.

Patients who have experienced medication errors can lose faith in the healthcare system and become anxious about future treatments. This loss of confidence can have a major influence on their overall health outcomes and desire to seek treatment. Furthermore, patient safety problems risk healthcare workers (Mahat et al., 2022). Employees can experience heightened tension and be concerned; as well as apprehension about criticism or legal penalties, all of which can have an impact on their job performance and well-being. 

In the end, assuring the integrity and efficacy of the healthcare organization depends on addressing these safety concerns in order to preserve patient and healthcare worker trust and safety.

Burnout and chronic stress may occur in the healthcare personnel who are apprehensive about making mistakes or seeing blunders (De Hert, 2020). This might result in negative publicity, lawsuits, and significant harm to their reputation. Consequently, their job may be at risk and the quality of treatment they offer might begin to decline.

Unresolved patient safety risks can eventually lead to serious organizational concerns. Failure to prioritize patient safety can lead to legal challenges and financial losses, affecting the healthcare facility’s long-term existence. The organization may face legal and financial consequences, as well as reputational damage, risking its accreditation and certification status with regulatory bodies such as The Joint Commission.

Institutions must respond quickly to any reported patient safety issues and constantly create a culture of worker reporting. Patients will seek alternative care if they lose faith in their healthcare practitioner or organization (Lu et al., 2022). Failure to respond to patient safety incidents can undermine the organization’s image in the community. By addressing these challenges, the organization may collaborate with patients to reduce possible damage and hazards, thus assuring confidence and safety in the treatment provided.

Regulatory Agency Role and Impact

The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) are the two primary regulatory bodies for hospital groups. CMS-accredited hospitals are permitted to admit and charge Medicare and Medicaid beneficiaries. The payment rates are based on a star rating system, which hospitals acquire by satisfying safety requirements, reducing patient damage and injury, and providing positive patient experiences (LaPelusa & Bohlen, 2023). Medication mistakes are one of the elements that impact a hospital’s star rating as evaluated by CMS.

Membership in The Joint Commission is not required, but it is an important regulatory agency for hospitals seeking Medicare or Medicaid money. The Joint Commission is a non-profit organization that tackles patient safety concerns and guarantees that patients receive high-quality, safe treatment (Wadhwa & Huynh, 2023). Accreditation by The Joint Commission indicates a commitment to upholding high standards of patient safety and care quality, which is required for getting and keeping CMS financing.

Role of the Patient Safety Officer

An organization’s Patient Safety Officer (PSO) serves as a patient advocate, supervising the quality and safety of treatment provided. Establishing a dedicated PSO role improves responsibility and patient safety within the business (Kagan et al., 2023). A strong awareness of policies, processes, and workflows is required for the PSO to successfully cooperate throughout the business. The PSO promotes a culture of health and safety for patients by doing frequent rounds and observations (Kagan et al., 2023). According to research, having a PSO at a hospital decreases patient falls considerably by continually monitoring bed locks, guaranteeing adherence to fall prevention measures, and removing possible trip hazards (Turner et al., 2020).

At Vila Health, the PSO’s responsibilities include evaluating the patient’s clinical state and ensuring that a treatment plan is implemented as needed. To pinpoint the exact site of a mistake or communication breakdown, the PSO will consult with the nurses and other personnel involved in the care of the two patients. Once the source of failure has been determined, the PSO may assess clinical processes and identify the necessary extra training.

Aside from advocating for patient interests, the PSO is also responsible for instilling a culture of collaboration and teamwork among staff by providing them with the resources they need to report patient safety problems. Employees tend to be discouraged from reporting instances if they fear penalties or reprimands, and the threat of legal action can make it even more difficult to disclose errors. As a result, a healthcare institution must educate its employees on the necessity of advocating for safety, as well as create an environment in which employees feel comfortable reporting events without fear of consequences.

Evidence-Based Best Practice Tools

As the first stage of Vila Health’s five-point strategy, a meeting will be held before each shift change to go over any critical patient care information. This huddle will allow healthcare professionals to identify any red flag zones. If there are patients with identical names or characteristics on the same unit, the clinical team will be separated into two different units for the duration of their stays to avoid cross-care.

The healthcare facility will next deploy barcode scanning for all drugs administered, eliminating human error and ambiguity in drug identification (Mulac, 2021). This system will ensure proper medication administration by matching the correct drug to the intended patient and alerting when the erroneous medication is attempted to be administered.

The final two processes are concerned with patient safety and the establishment of a system of checks before drug administration. Staff will have an additional person cross-check their work, verifying that the medicine name matches the order in the system and the barcode matches the patient. When the healthcare professional enters the patient’s room, they will scan the barcode on the patient’s wrist tag and get vocal confirmation from the patient of their name and date of birth.

These methods will work together to reduce patient safety mistakes. Every healthcare institution must follow the five key principles of medicine administration: administering the right medicine to the right patient, in the right amount, via the correct channel, and at the appropriate time. Implementing this approach at Vila Health will significantly improve patient safety and eliminate medication mistakes.

Conclusion – BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

Medication errors are not uncommon in the medical industry. Individuals working in this sector must understand how these errors occur, why reporting them is important, the repercussions of not reporting them, and what happens when they are reported. Education is one of the most effective ways to reduce patient safety problems.

Patients have the right to know what happened and what steps will be taken to protect their safety if a drug mistake happens. Once a patient’s faith in their healthcare provider has been damaged, they may never seek medical care from that doctor or institution again. Learning from medical errors can provide healthcare practitioners with the knowledge they need to safely treat patients in the future, eventually enhancing patient care and safety.


BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: De Hert, S. (2020). Burnout in healthcare workers: Prevalence, impact and preventative strategies. Local and Regional Anesthesia, 13(PMC7604257), 171–183.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Huang, C.-H., Wu, H.-H., Lee, Y.-C., & Li, X. (2024). The Critical Role of Leadership in Patient Safety Culture: A Mediation Analysis of Management Influence on Safety Factors. Risk Management and Healthcare Policy, Volume 17(PMC10929255), 513–523.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Kagan, I., Arad, D., Aharoni, R., Tal, Y., & Niv, Y. (2023). Crisis management for Patient Safety Officers: lessons learned from the Covid-19 pandemic. Israel Journal of Health Policy Research, 12(1).

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: LaPelusa, A., & Bohlen, J. (2023). Medicare and Medicaid Accreditation and Deemed Status. PubMed; StatPearls Publishing.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Lu, L., Ko, Y.-M., Chen, H.-Y., Chueh, J.-W., Chen, P.-Y., & Cooper, C. L. (2022). Patient safety and staff well-being: Organizational culture as a resource. International Journal of Environmental Research and Public Health, 19(6), 3722.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Mahat, S., Rafferty, A. M., Vehviläinen-Julkunen, K., & Härkänen, M. (2022). Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data. BMC Health Services Research, 22(1).

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Mulac, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Rodziewicz, T. L. (2023). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Tariq, R. A., & Scherbak, Y. (2023). Medication Dispensing Errors and Prevention. National Library of Medicine; StatPearls Publishing.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: The Joint Commission. (2024). National patient safety goals.

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2020). Fall Prevention Practices and Implementation Strategies. Journal of Patient Safety, 18(1).

BHA FPX 4004 Assessment 1 Address a Patient Safety Issue: Wadhwa, R., & Huynh, A. P. (2023). The joint commission. PubMed; StatPearls Publishing.

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