1. Using the GCU Library, locate and summarize an allied health malpractice or negligence case study. If possible, select a case within your chosen field of study. What went wrong? What workplace safety, risk management, and/or quality improvement steps were involved? What could have been done differently? If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan? You are required to use and cite a minimum of two references from the GCU Library to support your response.

2. A formal risk management plan demonstrates a health care organization’s approach as well as support for risk management and, ultimately, patient safety. Accessing information from your own employer/organization or using the internet to find an allied health care organization located in your city or region, identify the goals and objectives, scope, and functions of an existing risk management plan. How does the plan “measure up” in terms of meeting ethical and legal responsibilities to stakeholders? How might you improve it? Explain. You are required to use and cite a minimum of two references from the GCU Library to support your response.

3. The Joint Commission launched the National Patient Safety Goals in 2003 and most recently updated the goals again for 2020. Many years have now passed since the inception of these goals. How has the overall focus of the goals changed in the intervening years? What conditions in the health care marketplace have driven the need for change? You are required to use and cite a minimum of two references to support your response.

4. Looking ahead, select one area of the current National Patient Safety Goals program and make a prediction as to what might change in that area based on technological or other advancements. Consider patient identification standards, communication processes, and infection control protocols, among others. You are required to use and cite a minimum of two references to support your response.

SOLUTION

1. Allied Health Malpractice / Negligence Case Study

Sample Case Study: Retinal Surgery Malpractice (from student use of GCU Library)

One commonly cited allied-health (or related‑health) case in GCU-assignment discussions involves a retinal detachment repair surgery in a 41‑year-old woman with comorbidities (diabetes, renal insufficiency) (Menke, 2014, as discussed in student papers). Course Hero

What went wrong: The patient was anemic on the day of surgery, but the anesthesiologist proceeded without adequately addressing the lab findings. During the procedure, the patient became bradycardic and eventually sustained anoxic brain injury, later dying. Course Hero
Risk management/quality failure:
- Preoperative assessment was insufficient — the patient’s lab abnormalities (anemia) were not factored in as a high-risk sign.
- Communication breakdown among care team: the PCP, ophthalmologist, and anesthesiologist did not coordinate effectively to adjust the plan based on the patient’s co-morbid status.
- Procedural risk mitigation (e.g., delaying surgery, optimizing patient) was not fully exercised.
What could have been done differently:
- Delay the elective surgery until the patient’s anemia was corrected or further evaluated.
- More robust “time-out” or pre-op check to ensure labs are re-reviewed by anesthesiology before induction.
- Better interdisciplinary communication: PCP, surgeon, and anesthesiologist should have a pre-op meeting given the patient’s comorbidities.
Risk management plan recommendations:
1. Pre-op Risk Stratification Protocol: Implement a standardized checklist for preoperative labs + critical thresholds (e.g., anemia) that trigger a mandatory review.
2. Interdisciplinary Preoperative Conference: For any high-risk patient, have a pre-op huddle among PCP, surgeon, and anesthesiologist to align on risk and plan.
3. Anesthesia “Go/No-Go” Criteria: Define explicit criteria based on labs or patient status for postponing surgery.
4. Reporting & Learning System: After any adverse event, conduct a root-cause analysis, share findings, and update protocols accordingly.

Support from Literature / Risk Management Theory:

According to Medical Error Reduction and Prevention (Rodziewicz et al., 2024), system‑level failures such as poor communication and latent errors (e.g., lab mismanagement) are common contributors to medical error. NCBI
Encouraging a “just culture” and implementing confidential error reporting can help identify weaknesses before they lead to harm. NCBI

2. Risk Management Plan in an Allied Health Organization

Because I don’t know your specific employer, I’ll use a hypothetical allied health clinic (e.g., a physiotherapy / rehabilitation clinic) to illustrate how this might be handled, referencing general risk management principles and ethical/legal responsibilities.

Goals and Objectives of a Risk Management Plan:

Patient Safety: Minimize patient harm by identifying and mitigating clinical risks (e.g., falls, treatment errors).
Legal / Regulatory Compliance: Ensure clinic operations comply with healthcare regulations, professional licensure standards, and insurance requirements.
Quality Improvement: Continuously improve practice quality by tracking incidents, analyzing trends, and implementing corrective actions.
Staff Training & Competence: Keep allied health professionals (physios, techs, assistants) up to date in best practices, documentation, and professional liability prevention.

Scope & Functions:

Incident Reporting System: A way for staff to anonymously or directly report near-misses, adverse events, or patient complaints.
Risk Assessment: Regular risk audits (e.g., for infection control, equipment maintenance, patient mobility) to proactively identify potential hazards.
Training Programs: Ongoing training for staff on safety protocols, documentation, informed consent, and patient communication.
Review & Feedback Loop: Monthly or quarterly review of reported events, root-cause analyses, and updates to policies.
Patient Engagement: Educate patients on safety (e.g., safe exercise, how to report pain or adverse reactions) to reduce risk.

Ethical and Legal Responsibilities to Stakeholders:

To Patients: The plan must ensure their safety and autonomy (informed consent), reducing harm and improving trust.
To Staff: Provides protection from liability, helps create a safe workplace, supports professional development.
To Regulators / Insurers: Demonstrates proactive risk management, which can reduce malpractice exposure and might lower insurance premiums.
To Leadership / Owners: Helps limit financial risk, reputational damage, and legal liability.

How to Improve It:

Stronger Just Culture: Promote non-punitive reporting so staff feel safe reporting errors or near misses.
Benchmarking & KPIs: Establish key performance indicators (KPIs) for safety (e.g., incident rate per 1000 patient visits) and compare against industry data.
Patient Feedback Loop: Regularly survey patients about safety perceptions, then use that data to shape improvements.
Technology Use: Use an electronic incident management system rather than paper, to streamline reporting, trend analysis, and corrective actions.

Supporting these suggestions, Medical Error Reduction and Prevention emphasizes the importance of system-level interventions, interprofessional collaboration, and creating a culture that encourages error reporting. NCBI

3. Evolution of the National Patient Safety Goals (NPSGs)

How the Focus Has Changed Since 2003:

Initial Focus (2003): Very tactical and prescriptive — early NPSGs prioritized very concrete, high-risk issues like patient identification, improving communication, safe medication use, wrong-site surgery, and preventing hospital-acquired infections. HCPLive+1
Over Time: The goals evolved to embed more systemic thinking, not just “what to avoid” but “how to build safer systems and culture.” Elements like alarm fatigue, more nuanced infection control, and risk of falls became more prominent. PSNet
2020 Updates & Beyond: The Joint Commission moved some previously “goals” into standard accreditation requirements, refocusing NPSGs on truly emergent, high-priority issues. HPN Online+1
2025–2026 Transition: Notably, Joint Commission is replacing the NPSGs with National Performance Goals (NPGs). The new NPGs elevate key topics such as staffing adequacy, suicide risk reduction, and other strategic issues. Joint Commission

Conditions Driving Change:

Greater complexity in healthcare (technology, care transitions, EHRs) demands more systems-level safety interventions.
Data and reporting systems have improved significantly, so organizations can track more nuanced safety trends (e.g., alarm fatigue, staffing).
Workforce issues: nurse / clinician staffing shortages, burnout — now staffing is directly recognized as a performance / safety issue. Nursa
Focus on equity: patient safety is increasingly tied to health equity, requiring organizations to address disparities systematically.

4. Prediction: Future of Patient Safety Goals

Area to Watch: Staffing & Workforce Safety

Given the shift in the NPGs, I predict that staffing adequacy and workforce safety will become even more tightly regulated and measured. Here’s how it might evolve:

Real-Time Staffing Analytics: Organizations may adopt real-time dashboards that monitor nurse / allied health staffing in relation to patient acuity, triggering automatic safety alerts when staffing is inadequate.
AI Predictive Modeling: Using AI to predict patient surges, staffing gaps, and risk of adverse events — helping hospitals optimize staffing proactively.
Wellness & Burnout Metrics: Performance goals will likely include staff well-being metrics (burnout rates, turnover) because workforce health is strongly linked to patient safety.
Standardized Staffing Ratios / Skill Mix Requirements: Over time, NPGs may move toward more prescriptive staffing models (or at least require documented “safe staffing plans”) to reduce performance risk.

These changes align with how the Joint Commission is already elevating staffing as a performance goal, underscoring staffing as a core safety and quality lever. Joint Commission