Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. “Quality and patient safety in health care have been on the forefront of the public’s mind since the publication of the Institute of Medicine’s (IOM) seminal report, ‘To Err Is Human,’ in 1999” (Johnson, Haskell, & Barach, 2016, pg. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.

Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall.

For this first assignment, you will assume the role of a patient safety officer at your local hospital. You will analyze a patient safety issue that occurred and then prepare a 5–7-page recommendation for senior leaders about why it is important to address the issue, along with your recommendations about how to address it. You will also need to detail the role you, as the patient safety officer, will play in helping the organization resolve the issue.

Demonstration of Proficiency

By successfully completing this assignment, you will demonstrate proficiency in the following course competencies. Refer to the scoring guide for further details.

  • Competency 1: Analyze the quality and performance improvement activities within the health care organization.
  • Competency 3: Analyze the importance of patient safety in health care.
  • Competency 4: Apply leadership strategies to quality improvement in a health care organization.
  • Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations for health care professionals.


Write a 5–7-page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue that occurred. Include an explanation of why it is important to address the issue and the role the patient safety officer will play in helping to resolve the issue.


To successfully complete this assignment:

  • Select one of the three scenarios from the Vila Health: Patient Safety simulation that interests you the most for further analysis in your assignment:
  • Scenario 1: Patient Identification Error.
  • Scenario 2: Medication Error.
  • Scenario 3: HIPAA/Privacy Violation.
  • Consult the readings listed in the assignment preparation study in Unit 1.
  • Review the Assignment 1 template (provided in the resources) which you will use to complete this assignment. This document is formatted and has space for completing all components of the assignment.


For the scenario you selected, write a 5–7-page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of the following in your paper and to address all of the points:

  • Apply the health care safety imperative to a patient safety issue.
  • Identify the issue you selected from the Vila Health simulation as the potential safety threat.
  • Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.
  • Identify the implications of not addressing threat.
  • Evaluate the risk to the patients, employees, and organization, if patient safety threats are not addressed.
  • What does the health care safety imperative say about the issue?
  • How does the health care safety imperative apply in this case?
  • Which regulatory agencies have oversight about the issue?
  • Analyze regulatory agencies’ role and impact on organizations’ patient safety programs.
  • What specifically do the regulations state about the issue? For example, you might consider the Joint Commission’s NPSGs.
  • What impact do regulatory agencies have on organizations’ patient safety programs?
  • How do health care organizations incorporate regulatory agencies’ guidance when establishing reporting and investigation best practices?
  • What are the potential consequences to the patients, employees, and organization, if the hospital fails to correct the threat?
  • Analyze the patient safety officer’s role in implementing patient safety plans.
  • Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.
  • Clarify your responsibility and role as the patient safety officer in this specific instance.
  • Provide one example from the literature to illustrate your points.
  • Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.
  • Describe your five-point plan to reduce or eliminate this patient safety threat.
  • What best practice tools or techniques does your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.

In a health care professional setting, recommendations to leadership would typically not be in APA format. However, your paper does need to conform to current APA format and style guidelines. It does need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assignment, however, please use double-spacing.

Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assignment. Your citations and references do need to conform to current APA guidelines.

Please review the Addressing a Patient Safety Issue Scoring Guide to ensure you understand the grading requirements for this assignment.

Additional Requirements

Your assignment should also meet the following requirements:

  • Template: Use the Assignment 1 template (provided in the resources) to complete this assignment.
  • Length: 5–7 double-spaced pages, not including title and reference pages.
  • Font and font size: Times New Roman, 12 point.
  • APA format: Your submission, including the body, citations, and title and references pages need to conform to current APA format and style guidelines. Do make sure that it is clear, persuasive, organized, and well written, without grammatical, punctuation, or spelling errors. You also must cite your sources according to current APA guidelines.

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