Discussion: Quality Improvement Initiative

NURS 8302 Discussion: Quality Improvement Initiative

Health care is evolving and respectfully requires improvement while providing quality services. When errors happen in patient care, it leads to patient safety events. Medication errors are increasing around the globe and becoming a major concern in facilities. Although medication is a preventable error, it can threaten the health of patients and lead to economic losses (Kang et al. (2019). “To collect a safety patient event and to analyze a root cause of patient safety event, reporting systems have been implemented in healthcare settings and patient safety organizations (Kang et al. (2019).”

Furthermore, fast track drug approval is also a medication problem and has grown in the past years coupled with the increasingly complex drug molecules and therapy regimens such as the use of biologics and other sensitive medications, drug-related complications are on the rise and require more than usual attention from all healthcare professionals (Alzahrani et al. (2021). Prescribing errors (PEs) is an alarming concern that is related to fast-track medication is leading a major medication safety issue (Alzahrani et al. (2021). Prescribing errors, a major medication safety issue, are a common cause of morbidity and mortality, both in community practice and in hospitals (Alzahrani et al. (2021). Medication errors is serious because of the possibility of an adverse events can leading to a devastating outcome. In my organization a medication error would elevate to administration, who would conduct a meeting with quality and began a root cause analysis.

References

Alzahrani, A. A., & Alwhalbi, M. M., & Asin, Y. A., & Kamal, K. M., & Alhawassi, T. M.

(2021). Description of pharmacists’ reported interventions to prevent prescribing errors among in hospital patients: a cross sectional retrospective study. Health Services Research, 21; 432. https://doi.org/10.1186/s12913-06418-z

Yoa, B., Kang, H., & Gong, Y. (2019). Data quality assessment of narrative medication error

reports. doi:10.3233/SHT1190146.

RE: Quality improvement initiative

Collapse

Br…, thank you for your response. As distant as it may seem prescribing error is still a problem in some hospitals. Many interventions are in place to decrease these errors tremendously, although it still too many. Prescribing errors (PEs)is a major medication safety

issue, are a common cause of morbidity and mortality in both the community and the hospital. (Alzahrani et al., 2021). Additionally, in hospitals almost 6.5% of mortality and morbidity incidents that are connected to PEs, although over half of these errors are preventable. Alzahrani et al. (2021), defines PEs as “a clinically meaningful prescribing error that occurs as a result of a prescribing decision or the prescription writing process resulting in an unintentional significant reduction in the probability of treatment being timely and effective or in increasing risk of harm when compared to generally accepted practice.” Furthermore, the high frequency of PEs in hospitals can also be attributed to hospital systems such as, inadequate training for medical staff, excessive workload or secondary to patient related factors, such as giving poor care to a patient. Multiple personnel are likely to be involved in medication events, such as physicians, pharmacists, nurses, which can complicate reporting the event (Yao et al., 2019).

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Discussion: Quality Improvement Initiative

References

Alzahrani, A. A., & Alwhalbi, M. M., & Asin, Y. A., & Kamal, K. M., & Alhawassi, T. M.

Yoa, B., Kang, H., & Gong, Y. (2019). Data quality assessment of narrative medication error

reports. doi:10.3233/SHT1190146.

Quality Improvement Initiative

Collapse

Discussion: Quality Improvement Initiative

Post a brief explanation of the QI initiative you selected, and why. Be specific.

First case start times are imperative to patient safety and hospital financial stability. The bottom line of first case start delays are effective communication between the various members of the care team (Jacobs & Duncan, 2009). Delays in treatment secondary to ineffective communication led to adverse events that disrupt departmental integrity, cohesion and patient safety. Clearly defined role expectations of the various parties involved in the patient care are the first step towards effective communication that facilitates efficient first case start times (Fezza & Palermo, 2011).

Explain how adverse events are handled in your healthcare organization or nursing practice, including an explanation of how this may impact both public and internal perspectives on healthcare quality.

Public access to national reporting databases that show how hospitals compare to one another in how they manage care pathways affords provides a depth of consumer awareness never seen before in the medical and nursing world. Patients have a right to know how well organizations faire on reaching benchmarks associated with treatment options and can choose whether to proceed with receiving care at these facilities. It is important that nurses and doctors keep this at the forefront of their personal practice models as well as incorporate this into organizational standards of practice. Reporting of adverse events that are later made public by governing agencies such as the Agency for HealthCare Research and Quality and Healthcare Cost and Utilization Project (HCUP). These two agencies provide data that can be used to compare mortality rates of GI hemorrhage between facilities and states. This organization collects disease condition and treatment data from a variety of care settings to generate information that can be shared nationwide and displayed for the public and private entities through the State Inpatient Database (Healthcare Cost and Utilization Project, 2016).

At Mount Siani West, the adverse event reporting system in use is called SafetyNet. This documentation system allows all personnel to report adverse events and near misses under anonymity. Events ranging from IV infiltration and falls to medication errors are entered into this reporting system and later evaluated by management. This is an internal process of reviewing system errors that have the potential of causing adverse events in patient care. It is a non-punitive process that leads to investigating gaps in care or practice that are later corrected at an administrative level.

Briefly describe the error rate from the article you selected, and explain how this may relate to your healthcare organization or nursing practice. Be specific and provide examples.

The domino effect in healthcare caused by the over prescription of opioids is an example of a national patient safety issue secondary to a gross error whose implications are still felt throughout the medical community. Patient safety surrounding the number, frequency, and dosing of opioids by some practitioners demonstrates a gross medical error that has lasting deadly effects for patients, their families and communities. Nursing errors associated with inappropriate and inaccurate pain assessment and management are an example of an error that proved to be detrimental to patient safety associated with narcotic use and prescription (Higgins & Herpy, 2021). Although no one could have predicted the depth and extent of the global opioid pandemic, the errors associated with not fully appreciating the root causes of patient’s pain and appropriate collaborative management strategies lead to an international crisis. Healthcare organizations and nursing practice have subsequentially placed more emphasis on accurately assessing pain, its frequency and duration on an individual basis while no long relying on opioids as a primary strategy (Higgins & Herpy, 2021). Incorporating organizational success at applying this strategy to pain management is a quality improvement tactic employed in various departments under pain management and assessment.

Reference:

Fezza, M., & Palermo, G. B. (2011). Simple Solutions for Reducing First-Procedure Delays. AORN Journal, 93(4), 450–454. https://doi.org/10.1016/j.aorn.2010.11.029

Healthcare Cost and Utilization Project. (2016). Statistical Brief #65. Www.hcup-Us.ahrq.gov. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb65.jsp

Higgins, M. C. S. S., & Herpy, J. P. (2021). Medical Error, Adverse Events, and Complications in Interventional Radiology: Liability or Opportunity? Radiology, 298(2), 275–283. https://doi.org/10.1148/radiol.2020202341

Jacobs, B., & Duncan, J. R. (2009). Improving Quality and Patient Safety by Minimizing Unnecessary Variation. Journal of Vascular and Interventional Radiology, 20(2), 157–163. https://doi.org/10.1016/j.jvir.2008.10.031