MODULE 3 MODULE 4 MODULE 5 MODULE 2 ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 2. Ethical 3. Ethical 4. Best Ethics 5. Metric 6. Current 7. Reality Check 8. Achievable 9. Refined 1. Ethics Standard Standard Practice Ethics Goal Improvement Issue Source(s) Description(s) Practice Goal “Should” “Is” with Exclusions The quality VHA Handbook There is an Adverse events Numerator: Current practice 1. Based on 95% of adverse Increase the % manager for 1004.08 ethical that cause harm was determined accreditation events that of adverse Number of surgical of obligation to to patients on by identifying all standard, is cause harm to events that events that found a Events to to patients surgical services adverse events required and patients on caused harm to cause harm to number of Patients harmful adverse should be that caused harm monitored; services will patients that were patients on instances in events that have to the to patients on point is 90% be disclosed to disclosed to surgical which been sustained patient or surgical services the patient or or personal 2. High level of that are events in t he course of representative over the past 6 personal representatives seriousness disclosed to the that caused care, including [unless patient is months through a ____________ where even one patient or harm that cases where the deceased review of incident occurrence Denominator: should have harm may not or reports. The would be been be obvious, or otherwise unable health records of representative Total number of to where there is to take part in the these patients adverse events from 65% to patients or potential for pro-cess, and were reviewed for that caused harm 3. High level of 95% by Q4, personal harm to occur in there is no a disclosure note. to patients on leadership 20XX. the future. surgical services support Currently, 65% of were not representative]. Exclusion(s): adverse events Method: 4. Challenge Patient is that cause harm to Record review goal would be patients on 98%. Sample size: incapacitated, or services are 100% otherwise unable being to take part in disclosed to Past Time frame: the pro-cess, or 6 months and there is no personal personal representatives. MODULE 3 MODULE 4 MODULE 5 MODULE 2
MODULE 2 MODULE 3 MODULE 4 MODULE 5 ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 6. Current Ethics Practice “Is” 7. Reality Check 8. Achievable Goal 9. Refined Improvement Goal The quality manager for surgical found a number of instances in which events that caused harm that should have been to patients or personal were not VHA Handbook 1004.08 of Events to Patients There is an ethical obligation to to patients harmful adverse events that have been sustained in t he course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Patient is incapacitated, or otherwise unable to take part in the pro-cess, and there is no personal Adverse events that cause harm to patients on surgical services should be to the patient or representative [unless patient is deceased or otherwise unable to take part in the pro-cess, and there is no representative]. Numerator: Number of events that caused harm to patients that were disclosed to or personal representatives ____________ Denominator: Total number of adverse events that caused harm to patients on surgical services Method: Record review Sample size: 100% Time frame: Past 6 months Current practice was determined by identifying all adverse events that caused harm to patients on surgical services over the past 6 months through a review of incident reports. The health records of these patients were reviewed for a disclosure note. Currently, 65% of adverse events that cause harm to patients on services are being disclosed to or personal representatives. 1. Based on accreditation standard, is required and monitored; point is 90% 2. High level of seriousness where even one occurrence would be 3. High level of leadership support 4. Challenge goal would be 98%. 95% of adverse events that cause harm to patients on services will be disclosed to the patient or personal Increase the % of adverse events that cause harm to patients on surgical that are disclosed to the patient or representative from 65% to 95% by Q4, 20XX. MODULE 2 MODULE 3 MODULE 4 MODULE 5
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