Paper Example on Adverse Events

Introduction

Adverse events are among the leading cause of death in the world. It is estimated that at least two hundred and ten thousand fatal adverse events occur annually (Allen, 2013). Some of the adverse events which are blamed for the large number of deaths include administration of wrong medicine, patient falls, medical errors, and hospital-acquired infections (Rafter et al., 2013). This adverse event analysis focuses on medication errors. These errors may include, administration of wrong medication, medication overdose or failure to administer any medicine at all. The review will then recommend strategies which can be used to mitigate medication errors based on a case of non-administration of medicine observed in a rural emergency department (ED).

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A sixty-two-year-old man was presented to a rural emergency department (ED). He had a history of diabetes, and at the time of presentation, he was complaining of hiccups, chest pains, and generalized weakness. After examination, the internist at the hospital ordered that the man be given aspirin and heparin drip from home. However, the nurse in the ED did not administer these drugs because she did not receive the orders from the internist. The man's condition worsened, and he ended up dying later. An autopsy conducted on his body revealed that he suffered an acute myocardial infarction and a rapture on the left ventricular free wall.

Analysis of the Missed Steps related to the Adverse Event

Analysis of the above case reveals that the nurse missed a crucial step in the delivery of care to the patient. When she failed to follow the orders given by the internist, the nurse compromised the safety of the patient. Her failure to follow the internist's orders can be directly linked to the configuration of the hospital's electronic health record. Its complex nature made it hard for the nurse to easily access the orders and this made her not to administer the drugs as the internist's instructions.

The case also shows that the nurse was completely unaware of the danger that the patient was in as a result of the chest pain. This can be attributed to her lack of exposure to the condition before this event. According to research, nurses in rural Eds have a lower chance of encountering high risk, low-frequency events such as the one the patient was suffering from (McKinney and Mohr, 2018). The lack of exposure to high risk, low frequency makes them less prepared to handle them whenever they arise.

It can also be seen that the Internist made the orders from home. Although the internist was concerned about the patient's condition, there is not much he could do apart from give instructions hoping that they would be acted upon. The lack of physical presence of a physician in a hospital further risked the patient's safety because there is a chance that his instructions may not be followed and whenever a deviation occurs, the physician may not be able to respond to it adequately. Rural hospitals have this problem, and even when the physician is available, he mostly works alone with a small team of nurses who have other responsibilities to attend to. Patient's safety is therefore compromised as it has been demonstrated in this case scenario (McKinney and Mohr, 2018).

Implications of the Adverse Event on Stakeholders

Whenever an adverse event occurs, the patient and their family are always the first victims to be affected. The healthcare professions who were in charge of the patient are the second victims while the hospital where the event occurs becomes the third victim. Patients and their families have the faith that seeking medical attention in hospitals will be beneficial and have positive outcomes on the health of the patient. Their confidence on the healthcare system to deliver positive outcome, however, erodes whenever a patient becomes fatally injured or loses their life as a result of negligence or the mismanagement of the patient's condition by the healthcare professionals (Bernhard, 2013). This erosion of faith may make them to doubt the effectiveness of the healthcare system. They may thus hesitate to seek medical attention in future.

The healthcare professionals who were handling the patient when the adverse events occur may also be adversely affected by the incident. Research has revealed that a significant proportion of healthcare providers become traumatized after either committing a preventable error or being a witness to an adverse event (Harrison, Lawton & Stewart, 2014). The ones who commit these errors that result in the occurrence of adverse events may lose confidence in their ability to deliver safe and quality care to patients (Harrison, Lawton & Stewart, 2014). Some may even suffer from depression or anxiety as a result of the event. Career damage is also another common thing that healthcare professionals have to deal with after committing a preventable error. Some of the healthcare professionals lose their jobs and are never employed again. The mistake they made taint their reputation forever.

The hospital where the adverse event occurs is also affected by this occurrence mostly as the third victim. Negative publicity associated with adverse events discourages patients from seeking medical attention at the health facility. The hospital also risks not being reimbursed money because Medicaid and Medicare services do not cover most of the preventable errors (Bernhard, 2013). The hospital may also be forced to spend more money in litigation fees and compensation if the families of the affected patients decide to sue the hospital for negligence.

Evaluation of Quality Improvement Technologies

Quality improvement (QI) technologies rely heavily on the transmission, organization, analysis, and display of data to help them identify sections which should be improved. Performance measures and reporting by health care professionals, therefore, play an essential role in QI. Visual Dashboards are the among the latest development in QI technologies used to improve a hospital's ability to provide quality care and to guarantee patient safety (Ghazisaeidi, 2015).

Studies reveal that hospitals which use data-driven dashboards can reduce their costs of operation while at the same time increasing safety for patients. The use of dashboards reduces the chances of human error from occurring thereby increasing the accuracy and efficiency of healthcare delivery (Weiner, balijepally, & Tanniru, 2015). The time used in delivering care is also significantly reduced because the amount spent in engaging the mind before making decisions is minimised.

The rural hospitals should, however, test the QI tool offering this technology to ascertain whether it fits into the unique clinical context that the hospital finds itself in. There are several characteristics of a QI tool that the management of the hospital can look for in a tool to determine whether it will be useful. The QI tool should be: easily customizable, secure, useful in information delivery and knowledge discovery, provide users with a visual design and alerts whenever a particular critical limit is being exceeded, and finally have system connectivity and be able to be integrated into the hospital's system (Karami, 2014).

Relevant Metrics of Quality Improvement for the Rural Hospital

Key Performance Indicators (KPIs) are the Backbone of a dashboard. They combine administrative and clinical data sets to measure the performance across all sections of an organization (Ghazisaeidi, 2015). Evidence-based academic literature informs what kind of KPIs will be added on a dashboard. Data for each KPI is then obtained from various sections in the organization which include human resource, accounts, and clinical sections.

The rural hospital can, however, broaden the scope of its KPIs to make them more effective in improving the quality of care and enhancing patient safety. The ED department at the rural hospital can include the number of patients who left the ED without being seen and the average number days that a patient stays in the hospital as KPIs. Other key performance indicators which the rural hospital's ED can add include the cost reduction per patient, the speed of onset of pain relief, time taken before a patient is attended to, and the number of times when physician orders were followed correctly (Dolan, Veazie, & Russ, 2013).

The results from a study conducted by Dolan, Veazie, and Russ, (2013) showed that the Dashboard could promote patient-centered care and the making of informed decisions. Weiner, Balijepally & Tanniru, (2015) record that St, Joseph Oakland Hospital was able to achieve increased accountability, improved unit performance while at the same time reducing the number of adverse events that occurred at the facility after it started employing data-driven dashboards in healthcare delivery. The above mentioned peer-reviewed studies provide evidence which prove the dashboard's effectiveness as a QI tool.

Outline for a Quality Improvement Initiative for the Rural Hospital

The Rural hospital can use the six-sigma model's DMAIC approach for quality improvement. DMAIC approach has five steps which can be implemented to improve processes in an organization. The first step is called Define, and it entails the identification of the key issues of the business. The second step is called Measure, and it requires one to understand how the organization currently performs. Analyse is the third step, and it involves the identification of the reasons behind the occurrence of errors (Huber, 2017). Improve is the fourth step and it requires the organization to come up with strategies and tools which it can use to improve the quality of its process. Control is the fifth and last step in the DMAIC approach, and it requires the organization to maintain the newly acquired levels of performance at the organization (Huber, 2017).

The use of this approach by the rural hospital will help it to proactively streamline its processes not only in the ED but the whole hospital. An improvement in the entire system will help the hospital prevent the communication gaps that led to the death of the 62-year-old man. It will also reduce preventable errors from being committed while at the same time increasing the hospital's level of organization.

Conclusion

Preventable adverse events have various adverse effects on the patient, his family, healthcare professionals, and the hospital facilities where they occur. These adverse events as it has been demonstrated above, occur as a result of weak hospital systems which are unable to provide quality care or patient safety. It has however been shown that the use of quality improvement tools can strengthen hospital systems, improve on the quality of care, increase patient safety and also reduce patient costs. Quality improvement initiatives in hospitals should, therefore, focus on the appropriate use of these tools in to improve quality and safety outcomes for their patients.

References

Allen, M. (2013, September 19). How many die from medical mistakes in U.S.hospitals? [Ongoing investigative report]. ProPublica. Retrieved from https://propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals

Bernhard, B. (2013, May 5). Medical errors leave devastating impact on families, professionals. St. Louis Post-Dispatch. Retrieved fromhttp://stltoday.com/lifestyles/health-medfit/health/medical-errors-leave-devastating-impact-on-families

Dolan, J. G., Veazie, P. J., & Russ, A. J. (2013). Development and initial evaluation of a treatment decision dashboard. BMC Medical Informatics and Decision Making,13(1), 51. Retrieved from https://searchproquestcom.library.capella.edu/docview/1347649264?pqorigsite=summon

Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015).Development...