Fluent Essays

Write a comprehensive analysis (5-7 pages) of an adverse event or near miss from your nursing experience. Integrate research and data on the event to propose a quality improvement (QI) initiative to your current organization. Introduction Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication. This assessment’s goal is to address a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities with a quality improvement initiative to prevent future incidents. Instructions For this assessment, you will prepare a comprehensive analysis on an adverse event or near miss that you or a peer experienced during your professional nursing career. You will integrate research and data on the event and use this information as the basis for a quality improvement (QI) initiative proposal in your current organization. The following points correspond to the grading criteria in the scoring guide. The subbullets under each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your adverse event or near-miss analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels relating to each grading criterion. Analyze the missed steps or protocol deviations related to an adverse event or near miss. Describe how the event resulted from a patient’s medical management rather than from the underlying condition. Identify and evaluate the missed steps or protocol deviations leading to the event. Explain the extent to which the incident was preventable. Research the impact of the same type of adverse event or near miss in other facilities. Analyze the implications of the adverse event or near miss for all stakeholders. Evaluate the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event. Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety. Describe any change to process or protocol implemented after the incident. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Analyze the quality improvement technologies put in place to increase patient safety and prevent recurrence of the near miss or adverse event. Determine the appropriateness of the technology application for a specific patient or situation. Research scholarly, evidence-based literature to learn how institutions can integrate solutions to prevent similar events. Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement. Identify the salient data associated with the adverse event or near miss that is generated from the facility’s dashboard. Note: Dashboard means data generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management. Analyze what the relevant metrics show. Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data. Use resources such as the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and the World Health Organization (WHO). Outline a quality improvement initiative to prevent the recurrence of an adverse event or near miss. Explain, from an evidence-based viewpoint, how your facility now manages or should manage the process or protocol. Evaluate how other institutions addressed similar incidents or events. Analyze QI initiatives developed to prevent similar incidents. Explain why they are successful. Provide evidence of their success. Propose solutions for your selected institution that can be implemented to prevent similar future adverse events or near-miss incidents. Communicate analysis and proposed initiative in a professional, effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling. Integrate relevant sources to support arguments, correctly formatting citations and references using APA style. Running head: ADVERSE EVENT OR NEAR-MISS ANALYSIS 1 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Adverse Event or Near-Miss Analysis Learner’s Name Capella University Quality Improvement for Interprofessional Care Month, Year Comment [JS1]: This submission is very well crafted according to the rubric. It is written in a scholarly voice and free of APA and grammatical errors. ADVERSE EVENT OR NEAR-MISS ANALYSIS 2 Adverse Event or Near-Miss Analysis Preventable adverse events are among the top causes of death in the United States. Estimates reveal that 210,000 to 400,000 fatal adverse events occur every year (Allen, 2013). Examples of preventable adverse events are hospital-acquired diseases, medication errors, and patient falls. The focus of this adverse-event analysis is medication errors, also known as adverse drug events (ADEs), such as medication overdoses or administration of wrong medicines. The analysis will recommend strategies to mitigate ADEs based on a case of medication overdose observed in the emergency department (ED) at TrueWill General Hospital (TGH), a multispecialty hospital in the United States. A 40-year-old woman was brought to the ED after suffering a seizure. Before she was discharged, she suffered a second seizure and the ED doctor prescribed 800 mg of phenytoin, an anti-seizure medication, to be given intravenously (IV). The ED nurse misread the prescribed dosage in the electronic medical record (EMR) and administered 8000 mg, which was 10 times greater than the prescribed dosage. The patient died soon after the lethal infusion (Manias, 2012). The incident shows that the nurse made a series of cognitive errors in medication management and missed key steps (Manias, 2012), which will be explained in the analysis report. Additionally, the analysis will examine the implications of adverse events on multiple stakeholders. Relevant evidence and metrics will be incorporated when making suggestions for improvement of patient safety at TrueWill General Hospital. Analysis of Missed Steps Related to the Adverse Event Emergency departments are susceptible to adverse events because of the unscheduled nature of patient presentation, urgency, and severity of cases. In such high-pressure situations, Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. ADVERSE EVENT OR NEAR-MISS ANALYSIS 3 clinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken by the nurse revealed several missed steps in the delivery of care. To begin with, the drug dispensing machines in the ED were stocked with phenytoin in 250 mg vials; the correct dose required only 3.2 vials. As the nurse had misread the dose, she needed 32 vials of the drug. She took the vials from three different drug dispensers and administered the dose using two IV bags as well as a piggyback line (Manias, 2012). The nurse did not question the difficulty in procuring and administering the drugs, nor did she ask anyone to validate her calculations. Furthermore, she was not asked why she was removing so many vials from the drug dispensers in the ED unit. The scenario also shows that the nurse was unaware of the toxic nature of phenytoin when administered in large quantities; she was unable to recognize the warning signs. Additionally, the fact that the nurse could remove 32 vials is evidence of the technical drawbacks of the automated drug-dispensing machines. The machines were not programmed to send out alerts when large quantities of medications, especially high-alert medications like phenytoin, were dispensed (Manias, 2012). They were also not synced to the patient’s medical record. Therefore, the machines contained no information on drug preparation or correct dosages and did not display any warning signs. Various systems factors such as communication, leadership, education, training, and innovation of health care technology influenced the ED nurse’s clinical performance. The factors originate from the adaptation of systems theory into health care (Huber, 2017). There are, however, areas of uncertainty regarding the factors becoming problematic in TGH’s scenario. For example, the nurse’s hesitation to consult her team could have been caused by staff management problems such as conflict, overwork, or shortage of ED staff. Similarly, her lack of awareness of Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. ADVERSE EVENT OR NEAR-MISS ANALYSIS 4 dosages and safety measures indicates gaps in education and training. Such problems are a result of a breakdown of systems factors. Further evaluation is essential to understand the root causes of adverse events and systems problems. Ignoring root causes can result in similar adverse events in the future and negatively impact the stakeholders. Implications of the Adverse Event on Stakeholders Since medicine is a profession that depends on interpersonal relationships, adverse events have emotional, psychological, and professional consequences on all stakeholders. Patients and their families are the first victims of adverse events, while health care professionals and the organization become the second and third victims, respectively (Mira et al., 2015). A similar inference can be made about the adverse event at TGH; the inference is supported by certain assumptions about the health care environment. General assumptions about health care are as follows: (a) quality health care is a result of positive relationships among all stakeholders (Huber, 2017); (b) stakeholders are part of a high-risk environment where errors in clinical practice are common; (c) health care professionals are not always responsible for errors, as errors are often caused by a breakdown in systems factors (Manias, 2012); and (d) errors diminish the morale and job satisfaction of health care professionals and lead to more adverse events (Huber, 2017). The analysis of implications for stakeholders begins with identifying how each category of victims is impacted. The first victims expect hospital stays and procedures to be safe and beneficial. When a patient suffers an injury or dies because of medical negligence, the family may feel aggrieved and may require counseling and support. They may feel unnerved and scared by health care professionals (Bernhard, 2013) and hesitate to seek medical treatment in the future. The study reported that health care professionals were traumatized after committing a Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. 5 ADVERSE EVENT OR NEAR-MISS ANALYSIS preventable error or witnessing an adverse event. They may lose confidence, abandon their careers (Bernhard, 2013), and experience anxiety or depression (Mira et al., 2015). Adverse events are damaging to careers, and nursing professionals may face difficulty in finding another job (Bernhard, 2013). Adverse events also affect the organization—the third victim—by damaging its reputation. Adverse events can discourage people from seeking treatment at a particular hospital (Mira et al., 2015). Moreover, as most preventable errors are not covered by Medicaid and Medicare services, the hospital may lose a significant amount of reimbursement money. It is important that health care organizations such as TGH find ways to minimize the impact of adverse events on stakeholders. The current trend in quality improvement (QI) is focused on reducing human errors through automation of health care technologies. In the case of TGH, the existing level of automation of patient records and drug dispensers is insufficient and must be replaced. The next section recommends and discusses the benefits of a popular QI technology—patient care dashboards. Evaluation of Quality Improvement Technologies Performance measurement and reporting by health care professionals are the crux of QI because transmitting, organizing, analyzing, and displaying performance data help in identifying areas that need improvement (Ghazisaeidi, 2015). A recent development in QI technologies is the introduction of visual dashboards. Dashboards are interactive performance management tools that use graphic and easy-to-use formats to present specific metrics or key performance indicators (KPIs) on a single computer screen (Ghazisaeidi, 2015). Implementing a dashboard can help TGH improve quality of care and patient safety. Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. ADVERSE EVENT OR NEAR-MISS ANALYSIS 6 Studies show that the use of data-driven dashboards improves patient safety and accelerates cost-reduction efforts. A dashboard reduces human errors in processes and minimizes the cognitive effort needed to make decisions, thereby saving time and increasing efficiency and accuracy. The KPIs aggregate data collected from various sources. For example, clinical data incorporated into a dashboard include patient information gathered from physician or nurse charts. A dashboard can also consolidate metrics about market dynamics, innovation for long- term sustainability, and availability of financial and human resources for managers to analyze (Weiner, Balijepally, & Tanniru, 2015). To help TGH efficiently customize the dashboard to its specific clinical context, the tool should be tested and evaluated using certain criteria. The categories for each criterion are as follows: (a) easy customization; (b) knowledge discovery; (c) security; (d) information delivery; (e) visual design; (f) alerts; and (g) system connectivity and integration (Karami, 2014). These criteria can be used for all types of dashboards and health care settings. While the design features are important, the dashboard is only useful if the KPIs provide valuable data. Hence, the selection and development of KPIs are critical steps in QI at TGH without which the organization risks ignoring areas that require corrective action (Ghazisaeidi, 2015). Relevant Metrics of Quality Improvement for TrueWill General Hospital The KPIs are the most valuable content in a dashboard. They measure performance across the organization using a combination of administrative and clinical data sets. To prevent overloading the electronic dashboard, only a limited number of KPIs concerning high-priority areas is selected. These KPIs are based on evidence-based academic literature. Data for each KPI is sourced from different source systems in the organization such as the accounting system, Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. 7 ADVERSE EVENT OR NEAR-MISS ANALYSIS human resources system, and clinical system (Ghazisaeidi, 2015). For example, clinical data are sourced from reports on whether clinicians treated the correct patient, addressed the equipment or supplies needed, prescribed the correct medication or anesthesia at the appropriate time, and detected patient allergies (Hagland, 2012). For the adverse event analysis report, the relevant KPIs will focus on clinical and patient-centric metrics. Health care agencies such as the Agency for Healthcare Research and Quality (AHRQ) have developed their own metrics that address various aspects of quality: patient safety, prevention quality, inpatient quality, and pediatric quality. TGH can customize its clinical and patient-centric KPIs for the dashboard from these aspects. Examples of relevant AHRQ metrics that are applicable to the ED adverse event include (a) death rate in low-mortality-diagnosis- related groups; (b) accidental puncture or laceration rate; (c) heart failure mortality rate; and (d) dehydration admission rate (AHRQ, 2015a, 2015b, 2015c). The ED department at THG can include other relevant KPIs in the dashboard such as (a) monthly averages for patient length of stay (inpatient and outpatient); (b) patients in the ED who left without being seen (monthly); (c) radiology test (CT scan and x-ray), start to final dictation turnaround time (Weiner, Balijepally, & Tanniru, 2015); (d) speed of onset of pain relief; (e) cost-reduction percentage per patient; and (f) risk of drug interactions (Dolan, Veazie, & Russ, 2013). The evidence base for the selected KPIs consists of peer-reviewed studies. Hagland (2012) proved the success of the dashboard for patient safety optimization at the Saint Luke’s Mid America Heart Institute, Missouri. The dashboard increased communication within medical teams, reduced safety errors, and improved coordination between the teams. Dolan, Veazie, and Russ (2013) studied the effectiveness of the electronic dashboard as a decision-making tool. The results showed that the dashboard had potential to foster informed decision making and patient- Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. ADVERSE EVENT OR NEAR-MISS ANALYSIS 8 centered care. Weiner, Balijepally, and Tanniru (2015) studied the integration of data-driven dashboards at the St. Joseph Mercy Oakland Hospital in Michigan. The study reported tangible benefits such as KPIs reporting reduced adverse event rates and intangible benefits such as increased accountability across the organization, self-improvement among nurses, and improved unit performance. The dashboard is just the technological component of quality improvement. TGH requires a broader QI framework that incorporates organizational strategies to overcome problems in the ED that resulted in the death of the patient. A suitable framework will be selected after evaluating different perspectives and data about quality improvement. Outline for a Quality Improvement Initiative for TrueWill General Hospital The health care industry has adopted many QI and measurement models over the years. Two popular models in quality improvement are the Six Sigma and LEAN models. Both models have similar goals: eliminate operational waste and defects to improve quality and efficiency of a system. The main difference between Six Sigma and LEAN is in the approaches to identifying causes of defects and errors. According to Six Sigma, variations in processes cause errors, while LEAN thinking highlights unnecessary steps as the cause of operational waste and errors (AHRQ, 2017). As both process variations and unnecessary steps can cause errors, the combination of the LEAN and Six Sigma models can be implemented at TGH as its quality improvement outline. The hospital can follow the LEAN Six Sigma model’s DMAIC approach. DMAIC is a five-step approach to process improvement: (a) define—identify key business issues; (b) measure— understand current levels of performance; (c) analyze—identify root causes of process errors; (d) improve—introduce strategies and tools to improve quality of process; and (e) control—maintain Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. 9 ADVERSE EVENT OR NEAR-MISS ANALYSIS new levels of performance across the organization (Huber, 2017). Implementing the LEAN Six Sigma into all units and departments—not just the ED—at TGH will help streamline processes proactively. By improving the whole system, the hospital can prevent communication gaps or errors, disorganization, and breakdown of faulty systems. DMAIC steps will allow TGH to enhance QI process using tools and strategies such as the dashboard. The Institute of Health Improvement’s Plan-Do-Study-Act (PDSA) model and the Baldrige criteria were other quality improvement perspectives that were considered (Huber, 2017). However, the PDSA insufficiently addressed specific types of errors caused by variations or unnecessary steps, unlike the LEAN Six Sigma model. The Baldrige criteria too were insufficient because their usage was more suitable for enabling educational excellence. Additionally, there is extensive evidence supporting the LEAN and Six Sigma models in quality improvement. While the LEAN Six Sigma model and dashboards have a high success rate, implementing the QI initiative depends on coordinated and collaborative efforts by multiple stakeholders. Teamwork enables TGH’s health care professionals to optimize systems factors and the quality of processes and prevent future adverse events. Conclusion The process of QI and ensuring patient safety is challenging because health care organizations must simultaneously provide the highest quality of services and introduce cost- reduction strategies. Quality improvement initiatives such as implementing dashboards must focus on finding and fixing the root causes of errors or process inefficiencies. To identify the root causes of errors, the organization should train health care professionals, update health care technologies, and open lines of communication to meet the expectations of patients for safe, timely, affordable, and quality care. Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. 10 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. ADVERSE EVENT OR NEAR-MISS ANALYSIS References Agency for Healthcare Research and Quality. (2015a). Prevention quality indicators. Retrieved from https://qualityindicators.ahrq.gov/Downloads/Modules/PQI/V50/PQI_Brochure.pdf Agency for Healthcare Research and Quality. (2015b). Patient safety indicators. Retrieved from https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/PSI_Brochure.pdf Agency for Healthcare Research and Quality. (2015c). Inpatient quality indicators. Retrieved from https://qualityindicators.ahrq.gov/Downloads/Modules/IQI/V50/IQI_Brochure.pdf Agency for Healthcare Research and Quality. (2017). Section 4: Ways to approach the quality improvement process. In The CAHPS ambulatory care improvement guide: Practical strategies for improving patient experience. Retrieved from https://ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi- process/sect4part2.html#4c Allen, M. (2013, September 19). How many die from medical mistakes in U.S. hospitals? [Ongoing investigative report]. ProPublica. Retrieved from https://propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals Bernhard, B. (2013, May 5). Medical errors leave devastating impact on families, professionals. St. Louis Post-Dispatch. Retrieved from http://stltoday.com/lifestyles/health-med- fit/health/medical-errors-leave-devastating-impact-on-families- professionals/article_0cb6f031-fbc6-5b8f-bed9-610163dbf2f8.html Dolan, J. G., Veazie, P. J., & Russ, A. J. (2013). Development and initial evaluation of a treatment decision dashboard. BMC Medical Informatics and Decision Making, 13(1), 51. Retrieved from https://search-proquest-com.library.capella.edu/docview/1347649264?pq- origsite=summon ADVERSE EVENT OR NEAR-MISS ANALYSIS 11 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Hagland, M. (2012). A dashboard for OR patient safety optimization. Healthcare Informatics, 29(8), 29–31. Retrieved from https://search-proquest- com.library.capella.edu/docview/1038458450?pq- origsite=summon&http://library.capella.edu/login\%3furl=accountid=27965 Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B. Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14 Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015). Development of performance dashboards in healthcare sector: Key practical issues. Acta Informatica Medica, 23(5), 317–321. Retrieved from https://search-proquest- com.library.capella.edu/docview/1727377974?pq-origsite=summon Karami, M. (2014). A design protocol to develop radiology dashboards. Acta Informatica Medica, 22(5), 341–346. http://dx.doi.org/10.5455/aim.2014.22.341-346 Manias, E. (2012). Looking for meds in all the wrong places [Case study commentary]. Retrieved from https://psnet.ahrq.gov/webmm/case/282/looking-for-meds-in-all-the- wrong-places?q=Looking+for+meds+in+all+the+wrong+place Mira, J. J., Lorenzo, S., Carrillo, I., Ferrús, L., Pérez-Pérez, P., Iglesias, F.,… Astier, P. (2015). Interventions in health organisations to reduce the impact of adverse events in second and third victims. BMC Health Services Research, 15(1), 341–350. Retrieved from https://search-proquest-com.library.capella.edu/docview/1780186926?pq- origsite=summon&http://library.capella.edu/login\%3furl=accountid=27965 Weiner, J., Balijepally, V., & Tanniru, M. (2015). Integrating strategic and operational decision making using data-driven dashboards: The case of St. Joseph Mercy Oakland Hospital. Journal of Healthcare Management, 60(5), 319–331. Retrieved from Comment [JS2]: I would suggest locating a more current reference. This reference is on the cusp of being outdated according to health care research standards of being less than five years. With this topic, I am sure there are more updated references that could be used instead. Comment [JS3]: This is another reference that should be updated for the above reasons. ADVERSE EVENT OR NEAR-MISS ANALYSIS 12 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. https://search-proquest- com.library.capella.edu/docview/1733617419?OpenUrlRefId=info:xri/sid:summon&acco untid=27965