A-Level Coursework: Hospitals and Public Health: Crises

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[. . .] 2).

"Patient Safety" and One Example Related to Kaiser Permanente

While Kaiser has protocols dealing with specific medical errors, its policy for disclosing errors to patients in order to promote patient safety is particularly laudatory. According to The Commonwealth Fund, Kaiser Permanente has developed a "multipronged" approach for disclosure of medical errors to patients, which greatly promotes patient safety. The principles forming the basis for Kaiser Permanente's philosophy are: high regard for patient care; ready communication about unanticipated bad outcomes; communicating to the appropriate parties; checking medical records; following up on treatment and providing closure; supporting the team devoted to patient care (McCarthy, Mueller, & Wrenn, June 2009, p. 3). Accordingly, Kaiser has employed proactive training for physicians, "situation management teams" and health care ombudsman to have open and meaningful discussions with patients and their families about bad events and medical errors, support health care providers as needed and facilitate valuable communication between the health care institution and the patient/family. (McCarthy, Mueller, & Wrenn, June 2009, p. 3). This open, communicative and positive culture has resulted in favorable feedback and greater awareness of medical errors/adverse outcomes among providers, patients and their families.

Systems Changes, Policies or Procedures Adopted by Kaiser Permanente to Reduce Medical Errors, Showing a Reduction in Medical Errors

In addition to the measures stated above, Kaiser has core values of reducing medical errors, accidents and hospital acquired infections and has consciously redesigned systems based on those values. For example, Kaiser redesigned its sepsis detection system with evidence-based practices, saved more than 1,100 lives in the past 2 years through this redesign. For another example, Kaiser has aggressively improved its health information technology and electronic health record system through HealthConnect®, providing its members with ready, constant access to their personal health information and care teams in order to increase patient self-management and improve health care outcomes (Kaiser Permanente, 2012).


The medical error crisis in America, causing tens of thousands of deaths per year, has been traced by some consumers to workload, stress and/or fatigue among health care providers, lack of time doctors spend with patients, too few nurses, and lack of coordination and communication among health care providers. Consequently, the health care industry struggles to deal with this crisis and Kaiser Permanente has, at least in some respects, stepped to the forefront in reducing medical errors. Through its six attributes of Information Continuity, Care Coordination and Transitions, System Accountability, Peer Review and Teamwork for High-Value Care, Continuous Innovation, and Easy Access to Appropriate Care, Kaiser Permanente has shown itself to be a model for effective health care. In addition, Kaiser's policy for disclosure of medical errors to patients/families and for learning from medical errors serves as a model for other health care organizations. Overcoming systemic barriers caused by sheer size/scope and a culture of fear, Kaiser Permanente has also specifically succeeded in the areas of sepsis detection and health information technology. As a result, Kaiser Permanente's core values of reducing medical errors, accidents and hospital acquired infections are succeeding in constantly improving health care services and resulting in public acknowledgement of its efforts.

Works Cited

BPHC Task Force on Patient Safety. (2001). Report of the BPHC Task Force on Patient Safety. Washington, D.C.: January.

HealthLeaders Media. (2012, June 6). Joint Commission updates: Sentinel events statistics. Retrieved on September 1, 2012 from Healthleadersmedia.com Web site: http://www.healthleadersmedia.com/content/QUA-250699/Joint-Commission-Updates-Sentinel-Event-Statistics##

Henry J. Kaiser Family Foundation. (2004). Five years after IOM report on medical errors, nearly half of all consumers worry about the safety of their health care. Washington, D.C.: Henry J. Kaiser Family Foundation.

Henry J. Kaiser Family Foundation. (n.d.). Medical malpractice policy. Retrieved on September 1, 2012 from kaiseredu.org Web site: http://www.kaiseredu.org/Issue-Modules/Medical-Malpractice-Policy/Background-Brief.aspx

Joint Commission on Accreditation of Healthcare Organizations. (2001, July 1). Revisions to Joint Commission Standards in support of patient safety and medical/health care error reduction: Effectie July 1, 2001. Retrieved on September 1, 2012 from JCAHO Web site: http://www.dcha.org/JCAHORevision.htm

Kaiser Permanente. (2012). Fast facts about Kaiser Permanente. Retrieved on September 1, 2012 from xnet.kp.org Web site: http://xnet.kp.org/newscenter/aboutkp/fastfacts.html

Kaiser Permanente. (2012, June 6). Kaiser Permanente hospitals among the safest in the nation. Retrieved on September 1, 2012 from xnet.kp.org Web site: http://xnet.kp.org/newscenter/pressreleases/nat/2012/060612leapfrog_hospital_safety_score.html

McCarthy, D., Mueller, K., & Wrenn, J. (June 2009). Kaiser Permanente: Bridging the quality divide with integrated practice, group accountability, and health information technology. New York, NY: Commonwealth Fund. [END OF PREVIEW]

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