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

NURS 8302 Discussion Quality Improvement Initiative ANSWER

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of these interventions are detrimental to the mindset of the dementia patients; and they often return confused, and withdrawn.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