Quality Improvement For Patient Safety

The healthcare field is filled with the need for quality and safety improvements interventions. Quality healthcare can be defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are compatible with current professional knowledge,” (Hughes, 2008). The majority of medical errors, according to the Institute of Medicine (IOM) report To Err Is Human, are caused by flawed systems and processes, not by individuals (Hughes, 2008). The intricacy of healthcare is amplified by inefficient and fluctuating processes, changing patient case mix, health insurance, disparities in provider education and experience, and plenty of other factors. The goals of efficacy and safety are targeted through process-of-care assessments, which assess whether healthcare practitioners follow methods that have been shown to meet the desired goals and avoid those that are susceptible to harm.

Case Scenario

Heparin-related medication errors have been well-documented in medical literature over the past years. Heparin is on the Institute for Safe Medicine Practices’ (ISMP) high-alert medication list, and when taken incorrectly, it can cause considerable patient harm. A couple years back six preterm newborns in the Neonatal Intensive Care Unit (NICU) at a hospital in Indiana were accidentally given a 1000-fold larger heparin dose than was intended for a line flush that took place in September 2006. Three of those six babies died. The following year in November of 2007, a similar incident occurred in Sothern California. Three newborns also received 1000-fold more heparin than was required for an intravenous flush. Luckily, all of these babies made it. Because it involved the win babies of a prominent celebrity, this tragedy attracted additional media attention.

Nurse/Patient Role in the Care Situation and the Relationship Between the Patient’s Care and the Outcome

When it comes to medication administration especially those of high risk, nurses play a crucial role in safely administering medication using the five rights of medication administration. Those five rights are as follows: the right patient, the right drug, the right dose, the right route, and the right time. In addition to the five rights nurses need to go through the process of double checking the medication to further verify that it is being administered correctly. In the case described prior, nurses have seemed to surpass this step as well as failed to accurately read the label on the vial prior to giving the medication.

What took place was a medication error that has been seen to occur frequently with heparin-associated medications. Arimura et al. (2008), described these events as a system failure where “1) failure to carefully and accurately read the label on the medication vial proper to administering the drug to the patient; 2) inaccurate filling of automated drug-dispensing cabnits (substituting 10,000 units/mL 1-mL for 10 units/mL 1-mL vials); 30 non-distinct “look-alike” labels on the heparin vials; 4) similar size of the heparin vials as bother were 1 mL vials; and 5) “factor of then” dosing errors”.

In regards to the infants, the parents play a huge role alongside the nurses to ensure proper support and education is being given to then throughout the course of their hospital stay. Parents should be learning and receiving explanations about their baby’s medical condition as well as their course of treatment. These roles and interventions are what make a healthcare team work together to ensure the best care possible resulting in safer and quality care. When one or even both fail to achieve their goals of providing patient centered care is when outcomes begin to decline. In this case nurses failed to appropriately administer a high-risk drug in additional to failing to educate parents on the high-risk medication. With that being said working in the NICU involves a high stress environment due to concerned parents and very sick babies fighting for their lives every day. This can cause desired outcomes to be harder to achieve because of the huge responsibility the units carry to ensure quality and safe care.

Quality Model Employed and Actions Taken

Quality care models are employed all through the healthcare field. They aim to assess the value of care and the structure of an organization in order to achieve the desired health outcomes. In the case of the neonates and heparin overdoes the quality care model that was used to address the issue was the Lean Six Sigma model. This model aims to get rid of defects. An error in healthcare can be the difference between life and death. By eliminating life-threatening errors using Lean Six Sigma, patient safety can be increased. Define-Measure-Analyze-Improve- Control (DMAIC) is a five-step strategy to process improvement used by Lean Six Sigma (Magalhães, Erdmann, Silva, & Santos, 2016).

The actions that were taken in response to the first heparin overdosing was the release of a safety alert by the manufacturer Baxter in February 2007. In the months coming Baxter had revised the labels of each heparin dosage vail to be able to distinguish which was which with better ease. The same day that the Indiana event occurred it was reported that The Pharmacy Department at Lucile Packard Children’s Hospital (LPCH) took rapid initiative to decrease the risk of this event happening at their hospital. 10,000 units/mL heparin solutions were withdrawn from the formulary by the Pharmacy & Therapeutics Committee, therefore eliminating their use and availability in the hospital. Heparin was added to the hospital’s “High Risk Medication List” and policy by LPCH leadership. All of the pharmacy’s heparin flush solutions (10 units/mL and 100 units/mL) in automated drug-dispensing machines were replaced with pre-filled syringes,reducing the possibility of “look-alike” vials (Arimura et al., 2008). The nursing team was immediately notified of the inaccuracies and trained on the adjustments made at LPCH to prevent similar errors in the future. At LPCH, all of these process enhancements were quickly reviewed and approved by the board agencies. These adjustments were communicated to the medical, nursing, and pharmacy staffs. Continuing pharmacy and nursing staff training was and should emphasize examining every element of a drug label as an initial and final check before a patient receives any medication, in addition to reviewing hospital-wide procedures.

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?

u=uphoenix&sid=ebsco&xid=1a76482a

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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