Patient Safety Case Study Paper

Patient Safety—Case Study #2
Sierra Billman, Morgan Burkholder, & Crystal Montgomery
Indiana University School of Nursing Protecting Our Patients
Patient safety is an area in which every hospital strives to excel. Patient safety is when an error is prone, but staff prevents it before it happens. There are hundreds of hospitals in the United States that want to improve patient safety. One case of this would be The Veterans Health Administration implementing changes to decrease the likelihood of patient injury. The case study we examined, “Creating a Culture of Safety in the U.S. Department of Veterans Affairs Health Care System,” explains 1997 the system began changing the culture of safety. The Department of Veterans Affairs (VA) started this process by establishing an organization called National Center for Patient Safety and by 1999 it was finally created (McCarthy & Blumenthal,
The change process is as follows: assess, plan, implement, and evaluate (Sullivan, 2013). The difference found in the nursing process is the diagnosis step which becomes after assessment and before planning. Since the two processes are so similar it should be easy for us as nursing students to remember the change process and understand why the order of the steps is vital to our success during our careers. Change is inevitable in our profession, so it is important to know what type of change is occurring as well. Our group concluded that the empirical-rational model of change strategies best fits the information from the case study. Change occurred in the VA hospital because influence moved from the people who knew to those who did not know. This kind of influence is indicative of the empirical-rational model of change (Sullivan, 2013). Examples of this model include initiating technology that has been researched—the bar coding and electronic medication systems—which end up improving the quality of care (Sullivan,