NURS 8302 Discussion: Quality Improvement Initiative ANSWER

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

RE: initial Post Week 6

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CMS has defined quality improvement (QI) as a systematic process used to improve and standardize care, identify and reduce variation, achieve predictable results, and to improve outcomes w

ithin the health care systems for patients and organizations (CMS, 2021). The QI project that I would like to initiate is a plan to reduce return to hospitalization (RTH).  The goal is to reduce RTH by 50% in 6 months.  The geriatric population is exceptionally vulnerable of undergoing an adverse event associated with frequent rehospitalization. Research has shown that RTH especially in the elderly community can adversely affect their overall quality of life. In an article by Admi et al. (2015) they discussed “hospitalization of the older adult is often followed by an irreversible decline in the functional status that affects their quality of life and well-being after care”(Admi et al., 2015). In the acute care setting elderly patients are more likely to be subjected to physical and chemical restraints, foley catheters insertion and restrictions in movement in the efforts to keep them safe. Some of these interventions are detrimental to the mindset of the dementia patients; and they often return confused, and withdrawn.

Currently we address adverse events based off the event that triggered the need for change. I have determined that most of the events on my facility are handled from a reactive point of view; meaning the adverse events usually take place and triggers a quality improvement initiative. As a Director of Nursing (DON) and a DNP prepared nurse my focus is to change the culture of this practice.  Being reactive and waiting for an adverse event to happen alters the perception of the physician, patient, families, and community understanding of the abilities and capabilities of staff in the long-term care setting.  Unfortunately, it leads individuals to believe that long-term care facilities are not capable of providing quality care.  As a DNP prepared nurse, I know this is where quality evidence-based practice comes into play.  By re-visiting policy and procedures, and incorporating new standards of care and algorithm; a re-education of old processes can be reintroduced.  Quality care must be addressed as an action and re-iterate into every day practice.

In an article by Hudali et al. (2017) they discussed how the utilized a transitional care model (TOC) to address and reduce the RTH rate of their project study.  It was determined that 10.6% RTH was noted within the study population, approximately 40 patients out of 378 (Hudali et al, 2017).  It was noted that this rate dropped to 3.8% with the use of TOC model.  I found this information imperative for two reasons: many times, new patients transition for acute care setting to short-term rehab/long-term and we often transition these patients back home.  The study TOC model provided insight on examples and ways to utilize this model appropriately in my current setting to reduce and prevent rehospitalization of my population setting.  Medication reconciliation is one of  the most imperative aspects of the program along with teaching effective disease management from the patient perspective.

Reference:

Admi, H., Shadmi, E., Baruch, H., & Zisberg, A. (2015). From research to reality: Minimizing the effects of hospitalization on older adults. Rambam Maimonides Medical Journal, 6(2). https://doi.org/10.5041/rmmj.10201

Hudali, T., Robinson, R., & Bhattarai, M. (2017). Reducing 30-day rehospitalization rates using a transition of care clinic model in a single medical center. Advances in Medicine, 2017, 1–6. https://doi.org/10.1155/2017/5132536

Quality Measurement and Quality Improvement. CMS. (2021, March 3). Retrieved October 8, 2021, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement-.

Quality improvement aims to understand the complex healthcare environment, apply a systematic approach, and design, test, and implement modifications using real-time measurement to improve safety, effectiveness, and care experience (Jones et al., 2019). It is an opportunity to address concerns about how care processes and systems are delivered. Quality improvement (QI) is a team activity that collaborates with other disciplines, including patients, to improve care processes (Jones et al., 2019).  Done well, QI is a valuable process, enabling clinicians to deliver actual change to benefit themselves, their organizations, and their patients (Jones et al., 2019). This week’s discussion will focus on a quality improvement initiative, how adverse events are handled at my organization and impact public and internal perspectives on healthcare quality, and review a scholarly article where a serious error occurred and how this may relate to my organization.

QI Initiative Selected 

            I have been the co-chair of the Fall Prevention Quality Improvement Team for the network for several years. My co-chair and  I have led many fall prevention initiatives, including Dr. Patricia Quigley and Dr. Amy Hester’s (Hester Davis Scale for fall risk assessment) on-site visits to educate the network on fall prevention. I am fortunate to have met both fall prevention experts.

The QI initiative selected is a Fall Prevention Agreement to reduce fall events. I chose this QI initiative because I am passionate about fall prevention. This QI initiative was initially a Nurse Residency evidence-based project in 2018 and then expanded network-wide. Most patients are unaware of their fall risk. The Fall Prevention Agreement provides a standard format for communication between nursing staff and the patient, increasing patients’ knowledge of their fall risk factors. It is a two-sided agreement with specific fall prevention interventions and things the patient can do to prevent a fall. The nurse reviews the Fall Prevention Agreement on admission, and then after review, the patient and nurse sign/date the agreement. It is scanned into the electronic health record, being a permanent part of the electronic health record.

Adverse Events in My Healthcare Organizations 

My organization supports a just culture where colleagues are encouraged to do the right thing. It is a culture that promotes reporting and open discussion when adverse events occur. The aim is to avoid similar adverse events. Frontline staff is included in root cause analysis meetings to learn and discuss adverse events, identify opportunities for improvement, and implement action items to improve safety and quality of care. Research has shown that in units where feedback about adverse events is routinely given, staff have positive views on patient safety and are more apt to report adverse events (Liukka et al., 2017).

Leadership and the organizational structure play a vital role in developing and implementing QI plans (U.S. Department of Health and Human Services Health Resources and Services Administration, 2011). In my organization, senior leadership acknowledges the importance of discussing adverse events and encouraging frontline staff involvement in decision-making and policy development, positively impacting public and internal healthcare quality perspectives. I believe it is crucial to include frontline staff to gain a firsthand perspective on potential solutions. When firsthand perspectives are not discussed in the aspects of QI planning, the QI initiative may fail.

Published Scholarly Article that Recounts a Serious Error

            Medication reconciliation is an essential component of patient safety. The scholarly article I selected refers to a 71-year old female who accidentally received Navane, an antipsychotic medication, instead of her anti-hypertensive drug Norvasc for three months (da Silva & Krishnamurthy, 2016). She sustained physical and psychological harm, including ambulatory dysfunction, tremors, mood swings, and personality changes (da Silva & Krishnamurthy, 2016). Unfortunately, multiple healthcare providers overlooked her symptoms (da Silva & Krishnamurthy, 2016). Errors occurred at numerous levels, including prescribing, pharmacy dispensation, hospitalization, and outpatient follow-up. (da Silva & Krishnamurthy, 2016). The outpatient pharmacy accidentally dispensed Navan instead of Norvasc (da Silva & Krishnamurthy, 2016). Navane/Norvasc is one of many sound-alikes, look-alike drug names (da Silva & Krishnamurthy, 2016). “It is believed that preventable medication errors impact more than seven million patients and cost almost $21 billion annually across all care settings” (da Silva & Krishnamurthy, 2016, p. 1).

Related to My Healthcare Organization

Unfortunately, this alarming medication error can occur in any healthcare organization. At my organization, medications added to the formulary are evaluated for a look-alike, sound-alike potential with other products, and then appropriate safeguard education to staff. Look-alike and sound-alike medications are stored in red bins and different locations in the pharmacy. The regularly updated list appears in the policy manual and the pharmacy website. When possible, the electronic medical record system will place a warning comment and tall man letterings such as DOPAmine and DOBUTamine. My organization has developed a series of procedures to identify look-alike and sound-alike medications to prevent medication errors from these mix-ups. Medication errors are low but still occur. By creating a culture of teamwork and communication, we learn from our mistakes and aim to decrease preventable medication errors.

 

References

da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: A patient case and review of Pennsylvania and national data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 31758. https://doi.org/10.3402/jchimp.v6.31758

Jones, B., Vaux, E., & Olsson-Brown, A. (2019). How to get started in quality improvement. BMJ, k5408. https://doi.org/10.1136/bmj.k5437

Liukka, M., Hupli, M., & Turunen, H. (2017). How transformational leadership appears in action with adverse events? A study for finnish nurse manager. Journal of Nursing Management, 26(6), 639–646. https://doi.org/10.1111/jonm.12592

U.S. Department of Health and Human Services Health Resources and Services Administration. (2011). Developing and implementing a QI plan. Retrieved October 3, 2021, from https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/developingqiplan.p

Quality Improvement Initiative

Initiatives for quality improvement are methodical, data-driven strategies aimed at enhancing both the safety and quality of healthcare delivery. Initiatives to increase quality are concentrated on providing timely, safe, equitable, efficient, and patient-centered care. Analyzing medical data as well as the methods and procedures utilized in the delivery of care might serve as the basis for such initiatives. This results in the identification of areas that require improvement as well as the processes and systems that can be fixed to raise the standard of patient care.

A Brief Explanation of the QI Initiative Selected

The decrease in hospital readmission rates is the QI project that I have chosen for this discussion. Hospital readmissions occur when a patient returns to the hospital within 30 days of being released from the hospital (Gupta et al., 2019). High rates of readmission to hospitals present a serious problem for medical facilities and staff. High rates of hospital readmission also put a burden on healthcare resources and jeopardize patient outcomes. High readmission rates pose a danger to patient safety since they can result in unfavorable outcomes like increased stress levels and high death rates (Wadhera et al., 2019). Because it aims to address the several drawbacks connected to high readmission rates, a quality improvement project to lower hospital readmission rates is therefore a wonderful idea. By delivering high-quality care and improving patient outcomes, lowering hospital readmission rates guarantees lower healthcare costs (Wadhera et al., 2019).Initiatives aimed at enhancing quality are motivated by the necessity to assure the safe provision of medical care. According to Gupta et al. (2019), the six main objectives of patient care are to guarantee that medical treatment is equitable, timely, safe, effective, and patient-centered. As part of a quality improvement program, lower hospital readmission rates are linked to higher patient satisfaction and better medical results.

How Adverse Events are Handled in the Healthcare Organization or Nursing Practice

Including an Explanation of How This May Impact Both Public and Internal

Perspectives on Healthcare Quality. 

Unforeseen incidents frequently occur in the healthcare industry, and the way these incidents are managed can greatly influence the public’s and internal perceptions of the quality of service. According to Young et al. (2019), an adverse event is any unplanned or unforeseen incident that causes harm to a patient or causes them to become temporarily or permanently disabled. A healthcare provider must notify the patient and their family about an unfavorable event that has occurred. According to Hernández et al. (2023), the healthcare practitioner also needs to pay attention to the patient’s and their family’s worries and complaints regarding the adverse event. Following discussions with the patient and their family, a system of documentation has been established. The medical facility mandates that all adverse events be reported, noted, and documented. The counseling department provides emotional support to patients and their families, assuring them that all feasible measures will be made to mitigate the negative impact of the unfavorable incident. Transparency is ensured by the healthcare facility through communication with patients and their families, which increases patients’ trust in the hospital. Acknowledging and accepting culpability by acknowledging a negative incident According to Rodziewicz and Hipskind (2020), maintaining communication guarantees that patients and their values are acknowledged and honored. Healthcare practitioners are aware of the need to be open and honest. Negative occurrences should be reported, noted, and documented to identify areas that need improvement (Hernández et al., 2023). This is important because it guarantees that by fixing system flaws or other error sources that caused the unfavorable outcomes, they can be prevented in the future. Healthcare personnel understand that they won’t be criticized or shamed, according to the internal perspective on this. Nonetheless, it is expected of all healthcare workers to accept ownership and responsibility for their actions. The public gains greater faith in the healthcare organization when such incidents are disclosed and addressed because they know that ongoing quality improvement programs will be implemented to prevent such incidents in the future (Rodziewicz & Hipskind, 2020).

Error Rate From the Selected Article and How This May Relate to the Healthcare

Organization or Nursing Practice.

I chose a news statement issued on January 9, 2022, by the Michigan Department of Attorney General for this section. According to the report, a nurse was accused of seriously injuring a vulnerable adult’s physical and emotional health. The report claims that the nurse discovered two incorrect medication doses that had been given to a resident of the Grand Rapids home for veterans where she worked while carrying out her duties as a licensed practical nurse (LPN) (Michigan Department of Attorney General, 2021). However, the nurse decided not to notify her doctor or supervisor of the mistake right away, which resulted in the patient suffering severe bodily and psychological damage. The frequency of these pharmaceutical errors is not mentioned in the paper. Even though this was an isolated instance, incidents like this still happen frequently, and considerable work needs to be done to stop them from happening again. The incidence of such severe prescription errors jeopardizes the health and well-being of patients who are in danger, as the article reports (Michigan Department of Attorney General, 2021). Furthermore, according to Rodziewicz, Houseman, and Hipskind (2018), these disputes cost healthcare institutions thousands or even millions of dollars in legal fees and compensation. The inability to report a medication error upon discovering it could have been due to various reasons, such as the inability to take responsibility for the patient’s health decline, fear of hospital management’s repressive responses, fear of legal liability, fear of punishment, fear of being perceived as incompetent, or a combination of these (Rodziewicz, Houseman & Hipskind, 2018). This story highlights the need, in my healthcare setting, for an honest and open system that allows medical personnel to report prescription errors without fear of reprisal, blame, or ineptitude. The healthcare organization should implement a plan that guarantees healthcare workers’ freedom to disclose such incidents even when they accept accountability for their acts (Rodziewicz & Hipskind, 2020). It is advisable to promote the reporting of medication errors as it facilitates transparency and offers a foundation for quality improvement initiatives aimed at averting such incidents in the future. (Hernández etal., 2023). Instead than placing as much emphasis on stigmatizing and assigning blame, it would be better to fix system flaws or get rid of things that encourage prescription errors.

Conclusion

The provision of safe, effective, equitable, efficient, timely, and patient-centered care is the main goal of quality improvement activities. Reducing hospital readmission rates is one such effort, which is crucial since it improves patient outcomes, better patient satisfaction, lower medical expenses, and better care quality are a few benefits.An efficient reporting mechanism, open and honest contact with patients and their families, and the recording and documentation of such occurrences can all help manage adverse health impacts in healthcare more skillfully. Adhering to such protocols improves openness and helps healthcare organizations pinpoint areas where quality has to be improved (Gupta et al., 2019).