Use hard data to secure emotional engagement by using patient stories and voices.
Review the following lectures:
Quality
Performance Enhancement Measurements
Discussion Questions
Introduction:
Case Study Twenty-Four: Medication Error
You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s an elderly lady in her late ’70s who recently had a colon surgery. She is also the wife of a prominent physician at the hospital. She has been known to be somewhat confrontational with the nursing staff. However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often complains, you are somewhat concerned about this observation and decide that it would be best to check on this. You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse, who states that, as ordered, she had given the patient 80 units of insulin.
You immediately become quite alarmed, as this is an extraordinarily large dosage. You make sure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every fifteen minutes for the next two hours. To follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman 8.0 units of insulin.
You can readily see how this could easily appear to be 80 units. You meet with the charge nurse, the nursing supervisor, the director of nursing, and the treating nurse to determine what can be done to prevent this type of error in the future.
Tasks:
Discussion Questions
What are the facts in this case?
What are the management issues that need to be addressed in this case?
Is it reasonable for the nurse to have given this dose of insulin?
Should the nurse have questioned giving this large amount of insulin without checking with the doctor?
Should the pharmacist have questioned the dosage?
What mechanisms can be put in place to prevent this from occurring in the future?
Should this be considered a sentinel event? Should a root cause analysis be performed?
Submission Details:
To support your work, use your course and textbook readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.
Your initial posting should be addressed at 500–1000 words as noted in the attached PDF. Submit your document to this Discussion Area by the due date assigned. Be sure to cite your sources using APA format.
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
Focusing on creating a stronger foundation of education on patient safety
Mandating a nationwide reporting system to encourage timely reporting of errors
Increasing the standards of performance for healthcare providers
Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Presents information about the challenges to patient safety in today’s healthcare industry and the steps that are being taken to educate healthcare professionals to counter them.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Presents information about the challenges to patient safety in today’s healthcare industry and the steps that are being taken to educate healthcare professionals to counter them.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Presents information about the challenges to patient safety in today’s healthcare industry and the steps that are being taken to educate healthcare professionals to counter them.
Convince People That There’s a Problem
Use hard data to secure emotional engagement by using patient stories and voices.
Presents information about the challenges to patient safety in today’s healthcare industry and the steps that are being taken to educate healthcare professionals to counter them.
Leadership
Getting leadership for quality improvement right requires a delicate combination of setting out a vision and sensitivity to the views of others. “Quieter” leadership, oriented toward inclusion, explanation, and gentle persuasion may be more effective.
Reference
Dixon-Woods, M., McNicol, S., & Martin, G. (2012). Ten challenges in improving quality in healthcare: Lessons from the health foundation’s programme evaluations and relevant literature. BMJ Quality & Safety, 21(10), 876. doi:10.1136/bmjqs-2011-000760
References:
McCarthy, B. C., Jr., Tuiskula, K. A., Driscoll, T. P., & Davis, A. M. (2017). Medication errors resulting in harm: Using chargemaster data to determine association with cost of hospitalization and length of stay. American Journal of Health-System Pharmacy, 74(23 Supplement 4), S102–S107. doi:10.2146/ajhp160848
To Err is Human: Building a Safer Health System. (1999). Institute of Medicine. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
Additional Materials
From your course textbook, Cases in Health Care Management, review the following cases:
Case 23: Dialysis Access
Case 24: Medication Error
Case 25: Resistance to Operative Site Marking
Case 26: Surgical Need or Greed?
Performance Enhancement Measurements
The drive to improve quality care depends upon reducing errors to limit the overuse, misuse, and underuse of services. The required use of health information technology (HIT) supports and enables improved practices in medicine and integrated and coordinated patient care (Yong, Olsen, & McGinnis, 2010). Problems with the documentation of patients’ discharge disposition status in their healthcare records increase the probability of adverse effects, not only for continuity of care and prevention of patient readmission but also on compliance with meaningful use and core measurement requirements in the hospitals and outpatient surgical settings. Additionally, discharge summaries serve to substantiate the medical necessity of admissions and coding diagnoses, procedures, and billing and therefore must be accurate to pass the scrutiny of auditors (Youngstrom, 2013).
To assess the problem of accurate documentation of patient’s discharge disposition, the status in health records calls for the use of performance enhancement measurements that scrutinize the percentage of error rates and duplicate files in the electronic master patient index. The application of policies and procedures, as well as templates in the health information systems, would ensure that the critical demographic data is correct and use them to attribute records across and within systems. These strategies address the preliminary point of capture as crucial front-end verification (Arrowood et al., 2013).
Additionally, use of front-end solutions such as matching algorithms, photography, biometrics, or fingerprinting should be employed to prevent errors in patient documentation. For records that are filled by more than one physician or practitioner, all signatures should be retained for every contribution to more easily identify whose entry is incorrect and therefore enable streamlining the correction process. Providing continuous training and establishing open lines of communication to health professionals on the importance of quality medical records are essential for continued growth and improvement (Arrowood et al., 2013).
Performance Enhancement Measurements
Review each tab to know more.
Quality of Physician Services
Quality of Hospital Services
Patient Experience of Care
Presents information about the criterions/measures currently being used for performance measurement in healthcare.
Performance Measurement Criterion
The types of measures reported include both clinical processes of care (e.g., did all diabetic patients receive a test to measure their level of blood sugar?) and care outcomes (e.g., how many diabetic patients had well-controlled blood sugar levels?)
Reference
Network for Regional Healthcare Improvement. (n.d.). Measuring healthcare performance. Retrieved from http://www.nrhi.org/about-collaboratives/performance-measurement/
References:
Arrowood, D., Choate, E., Curtis, E., DeCathelineau, S., Drury, B., Fenton, S., & Harper, M. (2013). Integrity of the healthcare record: Best practices for EHR documentation. Journal of AHIMA/American Health Information Management Association, 84(8), 58. Retrieved from http://library.ahima.org/doc?oid=300257#.WfqZQ1tSzIU
Yong, P. L., Olsen, L. A., & McGinnis, J. M. (Eds.). (2010). Value in health care: Accounting for cost, quality, safety, outcomes, and innovation (Institute of Medicine roundtable on value & science-driven health). Washington, DC: National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK50926/
Youngstrom, N. (2013). Discharge summaries take center stage: Risks grow with electronic health records. Retrieved from https://www.racmonitor.com/discharge-summaries-take-center-stage-risks-grow-with-electronic-health-records
Additional Materials
From your course textbook, Cases in Health Care Management, review the following cases:
Case 27: Surgical Site Infection
Case 28: Who’s That Guy?
Case 29: Wrong-Site Surgery
Case 30: Blood-Borne Incident in an STI Clinic
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.