Quality Improvement For Patient Safety

There is a huge demand for initiatives to improve quality and safety in the healthcare sector. The possibility that desired health outcomes will occur for people and populations is increased and is congruent with current professional knowledge, according to the definition of quality healthcare (Hughes, 2008). According to the Institute of Medicine (IOM) report To Err Is Human, defective systems and processes—rather than human error—are to blame for the bulk of medical mistakes (Hughes, 2008). Health insurance, varying patient case mixes, inefficient and unstable systems, differences in provider education and experience, and a host of other issues all contribute to the complexity of healthcare. Via process-of-care evaluations, which check whether medical professionals use procedures that have been proven to achieve the desired results and stay away from those that could cause harm, the objectives of efficacy and safety are targeted.

Example Scenario

Medication mishaps involving heparin have been extensively described in recent years’ medical literature. Heparin is a high-alert medicine, according to the Institute for Safe Medical Practices (ISMP), and when administered improperly, it can seriously injure patients. Many years ago, during a line flush in September 2006, six premature infants in the Neonatal Intensive Care Unit (NICU) of an Indiana hospital received an unintended dose of heparin that was 1000 times too excessive. These six infants lost three of them. A similar tragedy occurred in Southern California the following November. Moreover, 1000 times more heparin than needed for an intravenous flush was given to three babies. Fortunately, all of these infants survived. The fact that this tragedy included the win babies of a well-known celebrity drew further media attention.

The connection between the patient’s care and the outcome and the nurse/patient’s role in the care situation

Nurses play a critical role in safely giving medication following the five rights of medication administration, especially when it comes to high-risk medications. The right patient, the right drug, the right dose, the appropriate route, and the right time are the five rights listed above. Nurses must also check the medication twice to ensure further that it is being provided properly in addition to the five rights. In the situation previously discussed, nurses appear to have gone beyond this step and neglected to properly read the label on the vial before administering the drug.

What happened was a pharmaceutical error, which has been observed to happen regularly with drugs that contain heparin. As a result of a system failure, Arimura et al. (2008) identified the following events: “1) failure to carefully and accurately read the label on the medication vial prior to administering the drug to the patient; 2) inaccurate filling of automated drug-dispensing cabinets (substituting 10,000 units/mL 1-mL for 10 units/mL 1-mL vials); 30 non-distinct “look-alike” labels on the heparin vials;

The parents, along with the nurses, play a crucial role in ensuring that the infants receive the right care and instruction throughout their hospital stay. Parents should be informed about their baby’s medical condition and the recommended course of therapy. In order to provide the finest care possible, a healthcare team must collaborate in order to provide safer and higher-quality care. Results start to deteriorate when either one or even both of them fail to deliver patient-centered care. In this instance, nurses not only neglected to inform parents about the high-risk medication but also improperly administered a high-risk substance. As a result of worried parents and critically ill newborns fighting for their lives every day, working in the NICU is stressful. Because of the enormous duty, the units have to provide high-quality and safe treatment, and desired results may be more difficult to obtain as a result.

Use of the quality model and actions

The healthcare industry as a whole uses quality care models. In order to attain the intended health results, they seek to evaluate the value of care and an organization’s organizational structure. Lean Six Sigma was the quality care approach that was applied to deal with the problem in the instance of newborns and heparin overdoses. This design seeks to eliminate flaws. Healthcare mistakes have the power to save or end lives. Patient safety can be improved by employing Lean Six Sigma to eliminate errors that pose a life-threatening concern. Lean Six Sigma employs the Define-Measure-Analyze-Improve-Control (DMAIC) five-step process improvement methodology (Magalhaes, Erdmann, Silva, & Santos, 2016).

The first heparin overdose was addressed by the manufacturer Baxter, who, in February 2007, issued a safety advisory. Baxter updated the labeling on each heparin dosage vail in the upcoming months to make it easier to tell which was which. On the same day that the incident in Indiana happened, it was stated that the pharmacy department at Lucile Packard Children’s Hospital (LPCH) acted quickly to reduce the likelihood that a similar incident would occur there. The Pharmacy & Therapeutics Committee removed 10,000 units/mL of heparin solutions from the formulary, ending their use and availability in the hospital. Leadership at LPCH included heparin to the hospital’s “High-Risk Drug List” and policy. Pre-filled syringes were used in place of the pharmacy’s whole stock of heparin flush solutions (10 units/mL and 100 units/mL) in automated medicine dispensers to reduce the risk of “look-alike” vials (Arimura et al., 2008). The nursing staff was informed right away of the errors and given training on the modifications made at LPCH to avoid repeating them. All of these process improvements at LPCH were swiftly examined and accepted by the board agencies. The medical, nursing, and pharmacy staff were informed of these modifications. In addition to reviewing hospital policies, ongoing pharmacy, and nursing staff training emphasizes reading the entire prescription label as a preliminary and last check before a patient receives any medication.

References

Arimura, J., Poole, R. L., Jeng, M., Rhine, W., & Sharek, P. (2008). Neonatal heparin overdose-a multidisciplinary team approach to medication error prevention. The journal of pediatric pharmacology and therapeutics: JPPT : the official journal of PPAG, 13(2), 96–98. https://doi.org/10.5863/1551-6776-13.2.96

Hughes, R.G. (Ed.). (2008). Patient safety and quality: An evidence-based handbook for nurses. (2008). Nephrology Nursing Journal, 35(4), 431. https://link.gale.com/apps/doc/A184851976/AONE?

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Magalhães, A. L., Erdmann, A. L., Silva, E. L., & Santos, J. L. (2016). Lean thinking in health and nursing: an integrative literature review. Revista latino-americana de

enfermagem, 24, e2734. https://doi.org/10.1590/1518-8345.0979.2734

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This assessment is designed to highlight the role you play in high quality, safe patient care on a daily basis.

The Scenario

In an effort to continuously improve quality and safety, your manager has asked you to share one example of patient care from your experience. Your and other team members’ submissions will be used to help facilitate an upcoming training.

In a 700- to 875-word case study, address the following:

• Identify a patient care case from your own practice experience that involves quality and safety. Note: If you are not practicing or have not practiced, use a case that has received media attention or one from the textbook.
• Summarize the situation.
• Describe your (or the nurse’s) role in the patient care situation.
• Explain the role the patient played in their own quality- or safety-related situation.
• Evaluate the relationship between the patient’s care and the outcome.
• Identify how the care environment affected the situation, including the nurse or provider, the patient, and the outcome.
• Determine whether a quality model was employed. If yes, identify and explain it. If not, identify one that could have improved the situation.
• Explain what actions you might take to improve the outcome or prevent an adverse outcome in the future.

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