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Unformatted text preview: Running head: FINAL PROJECT- CASE STUDY Final Project- Case Study Southern New Hampshire University IHP 315 – Patient Safety Systems 2 FINAL PROJECT - CASE STUDY Abstract An error analysis is being examined on a twenty-year-old patient name Paul. Paul experienced a respiratory system failure and was treated at the Union Hospital Emergency Department. Throughout the patient care treatment phase, there were couple of critical incidents that resulted in further injuring the patient and at the end to his death. In the report, it will recommend measurable evidence-based patient safety improvement strategies. Key elements of disclosure that need to happen after an incident and what information the patient or family should receive. It will speak about the patient safety culture of the Union Hospital and propose ways it can improve the communication and teamwork. Keywords: patient safety, RCA, NPSG, TJC, TeamSTEPPS, HSOPS 3 FINAL PROJECT - CASE STUDY Final Project- Case Study 4 FINAL PROJECT - CASE STUDY Case B will be studied and analyzed for the cause that led to a medical error because of the negligence of the health care team at the Union Hospital Emergency Room. A twenty-year-old patient named Paul was admitted to the Union Hospital Emergency Department and was immediately seen by the E.R. physician because of shortness of breath. The E.R. physician diagnosed him with right lower-lobe pneumothorax after confirmation from a chest radiograph. The doctor ordered a thoracotomy insertion on the affected-side by the attending nurse. The nurse performed the chest tube on the opposite side where it was ordered, and because of timesensitivity time-out was not performed or consent signed. Paul’s respiratory problem got worst. The nurse informed the physician the wrong procedure was performed. Next, the physician informed the patient of the sentinel event. The nurse documented in the patient’s record of the incident. After, the physician attempted to transfer the patient to the OR to insert the chest tube correctly. The nurse supervisor informed the doctor no availability of inpatient beds at Union and needed to transfer to a five-minute away facility. The physician coordinated the logistics of the patient to transfer by communicating with the surgeon at Jefferson about Paul’s condition and submitted a STAT order to transport secretary. After the physician was done writing the transfer orders, the physician and nurse moved to the next patient. The unit secretary arrived late from her lunch break and didn’t see any transfer order come through. Around the same time, Paul’s oxygenation continued to diminish, and lost consciousness. The nurse went to reassess Paul and notice he has expired. [SNH1]. See Figure 1, for a quick synopsis of the events. 5 FINAL PROJECT - CASE STUDY In the scenario there were couple things that were contributing factors of the medical error such as poor national patient safety goals (NPSG) execution, communication breakdown, deficiency in environmental of care (EC), nonexistence provision of care (PC), and failure of honoring of patient’s rights and responsibilities of the patient (RI). First NPSG, the nurse did not use two identifiers with the patient to see if it was the right patient—NPSG 01.01.01; didn’t ensure correct procedure was performed by marking, pausing before the procedure and correct patient—UP 01.02-03.01 (TJC, 2018). Second EC, the nurse, the unit secretary did not know their roles and responsibilities during transferring a patient because the continuity of care was nonexistent—EC 03.01.01 (TJC, 2018). Third PC, the nurse failed to reassess it’s patient throughout the course of the care, treatment, and services—PC 01.02.01; failed to proper planning of the transfer of the patient—PC 01.03.01; provide correct individualized or recognized the change in patient’s condition—PC 02.01.0.1,19,21; and finally the emergency doctor and nurse didn’t follow through with the patient until transferred—PC 02.04.05 (TJC, 2018). Lastly RI, the attending nurse did not receive informed consent from the patient and failed to honor patient’s rights—RI 01,03.01; and improper communication from the doctor, nurse, unit secretary in the treatment of care or continuity of care—LD 02.01.01 [TJC18]. There was also sharp-end and blunt-end errors process that occurred. The nurse performed the wrong procedure on the patient, perform a time-out before the procedure and failed to reassess/monitor the patient at the correct intervals. The unit secretary failed to check after the break if any orders were pending. Both are an Inactive error in the sharp-end. A latent error in the blunt process was a failure in the system of transferring a patient because it did not alert the staff (unit secretary) that order is coming through or pending that is STAT transfer [Duk16]. There should be an alarm/procedure in place to mark for immediate transfers. 6 FINAL PROJECT - CASE STUDY There are three medical errors that patient or Next of Kin can file for malpractice. First is a failure to follow standards of care. The nurse did not perform what the doctor’s order to specify, which caused the patient further injury. Second, failure to assess and monitor the patient. If there are no written policies in place, then a medical provider should have follow-on the patient to ensure the health was not deteriorating. All the staff had a duty to ensure the highest quality of patient care is rendered. The third is a failure to communicate when the nurse failed to report changes in the` patient’s condition of the physician, which cause a delay in care then death [Rei121]. 7 FINAL PROJECT - CASE STUDY A recommendation to fix the communication is using Team Strategies & Tools to Enhance Performance and Patient Safety or TeamSTEPPS (TS). Its five fundamental values are Communication, Leadership, Situation Monitoring, and Mutual support [AHR18]. This is an evidence-based framework that will optimize the healthcare team to provide top quality care. Communication can improve by using “Call-out,” which it will inform all the team members situation, direct responsibilities, and anticipate next steps [AHR18]. Next using “Check-Back,” which the team members will use a closed-loop communication to ensure information was received correctly. Lastly, “handoff,” a person in the team who received all the information and check-back assumes responsibility and authority and ensures proper transfer is conducted. “I PASS THE BATON” is used. 1) Introduction, 2) Patient, 3) Assessment, 4) Situation, 5) Safety Concerns, 6) Background, 7) Actions, 8) Timing, 9) Ownership, 10) Next will be answered. The team events should consist of the short brief; first, team huddle to re-establish situational awareness and debrief to provide lessons to learn or reinforcement of positive behaviors [AHR18]. They can use the IDEAL checklist to have a system checklist to ensure standardization is occurring. During the team events such as short brief and team huddle, they should include the patient and family members so that they can be aware of situations and answer questions of the treatment. Then they can discuss with the patient, family, and healthcare team key areas to prevent problems during the procedure or discharge. Assess the understanding of the patient, family and team members to ensure can recall the information back. Last, is listen to everyone to ensure all concerns and goals are answers and explain [AHR181]. 8 FINAL PROJECT - CASE STUDY Measurement should be used in three phases: Assessment, Planning/Training & implementation, and Sustainment. Phase one is Assessment, or before training, there needs to be a site assessment, evaluation of the culture of safety, the collection of near-misses, and failure modes. The second phase is training & implementation, where the Hospital identifies areas of strength and weakness or barriers; developed a vision or expectations. Only until now TS can be incorporated. The last phase is sustainment. Data from phase one should be monitored every month/quarter/semi-annual/yearly, and a Patient Safety committee should be in charge of overseeing this process [AHA15]. This will also meet a requirement for The Joint Commission. By monitoring these time frames and conducting a report, patient safety will rise. Depending on the state, the patient is getting treated; there are either mandatory or voluntary reporting of near-misses, adverse events, and sentential events. Mandatory reporting is required when there is a severe adverse event (death or severe patient injury). A voluntary reporting is required when the mistake is less severe that resulted in no harm (near misses) or minimal harm. (Flowers & Riley, 2001, p. 3). The goal for mandatory reporting is accountability and voluntary for safety improvements or detection of systemic weakness (Flowers & Riley, 2001, p. 4). Mandatory reporting is required because they hold providers publicly accountable and provides data for research to minimize preventable errors. That information though can make the organization a higher target to increase malpractice litigation (Flowers & Riley, 2001, p. 31). New York was the first mandatory incident reporting state in 1986, and they report patient deaths, equipment malfunction, and unscheduled termination of services (Beckett, Fossum, Moreno, Galegher, & Marken, 2006). “According to a 2008 survey, only eight states in the US explicitly prohibited "admissions of fault" from being used as evidence at trial” (AHRQ, 2017). 9 FINAL PROJECT - CASE STUDY Federal guidelines for public health are established in the Code of Federal Regulations Title 42. It states hospitals must establish a procedure where a patient can submit a grievance to the hospital within a time frame of review and response (E-CFR, 2018). It also needs to state in a written notice the decision the hospital is taking, a point of contact, investigation outcome and date of completion. Furthermore, it is the patient’s right to be informed about their care. Using the State and Federal requirements, in this scenario, the provider could use University of Michigan model. First, follow the hospital’s rules in reporting patient safety reports. Second, the incident should be investigated impartially using a peer review official in the relevant field. This is necessary, so the hospital can choose the correct words before they claim anything. Third, the provider should contact the patient’s family and provide full disclosure of all the harmful errors, explaining why it occurred, and the steps taken next (AHRQ, 2017). If the patient or family engages in legal counsel, the organization should meet with both of them. If the error was legitimate, they should apologize and reach an agreement about a resolution. If the care was appropriate, assist them both in discussing the findings with an explanation. In the end, the incident should be studied, analyzed and use as a learning experience to educate the staff so that it will not happen again (UMHS, 2018). The Joint Commission (TJC) states, the hospital requires to collect and monitor patient care outcome data to understand the culture of safety in the organization. It also states the reporting requirement should be a non-punitive approach. Also, they require all sentinel events to be reviewed by the hospital and reporting to TJC is highly encouraged but not required. Their steps to report a sentinel event are to form a team response, disclose the event to the patient and family and provide support services to parties (staff and patient or family) involved. Also, notification of hospital leadership needs to occur, and immediate investigation with a completion 10 FINAL PROJECT - CASE STUDY date of a Root Cause Analyzes. They also require a corrective actions timeframe and systemic improvement timelines (TJC, 2018). Information that should be shared with TJC is a cause-andeffect relationship, the violation of the procedure, actions to eliminate the hazard and risks. Reports to the State Department of Health and Human Services should include demographics of the patient, type of sentinel event, location, a point of contact, description of the sentinel event, notification methods, and follow-up information (DHHS, 2018). Their goal is to improve care, understand the sentinel events and make changes to mitigate mistake (DHHS, 2017). To understand the patient safety culture of an organization, there has to be a Hospital Surveys on Patient Safety Culture (HSOPS) conducted in the department and facility. An AHRQ HSOPS can be conducted in the hospital to analyze the patient safety and quality of care; recognize areas to improve; examine trends over time; conduct comparisons within departments and across organizations; and establishing a culture of safety at the hospital[AHR16]. In the HSOPS User Guide, it states this survey should be conducted by every staff member from housekeeping to physicians because everyone plays a role in patient care. If the housekeeping does not keep the area sanitized or keep the floors dry, then it will cause the patient harm or fall hazard. The HSOPS is composing of 12 measures that will assist in gathering data about the environmental care, communication, teamwork, near-miss/error events reporting, non-punitive actions, staffing and management practices of the department or organization. If a survey would be conducted, then it will state that the patient safety culture of Union Hospital Emergency Department is lacksidiscal. The department lacked communication, situational awareness, poor handoffs and transitions, and overall perception of patient safety. They have violated NPSG/TJC guidelines, CFR policies, and possibility State laws. The staff performed 11 FINAL PROJECT - CASE STUDY a sentinel event; failed to receive consent from the patient; and failed to reassess the patient is throughout the treatment care. If the organization’s culture of patient safety was above standard, then the outcome of the patient should’ve been high-quality health care.[Mit08]. One way the facility could've had a stronger presence of patient safety has the leadership conduct walkthroughs. If the physician or supervisor conducted rounds, then they could've caught the near-miss or mishap or show their commitment to the culture[IHI]. Second, the organization should’ve had a patient safety representative in the department. This person job scope would be to promote patient safety; provide education of growing safety trends; and in charge of the error analysis of the department[INI]. Third, they should've involved the patient in the safety awareness and initiatives in their treatment. By adding the patient and their family, they add more layers to the defense against adverse events. They patient and family share the same interest as the organization of ensuring good health care[INI1]. For example, in this scenario, if there was a third-party in the room, then they could’ve stopped the nurse and intervene. A proposal to increase communication and teamwork is to implement TeamSTEPPS (TS). TS is endorsed by the American Hospital Association (AHA) because it is proven to improve communication, patient outcomes and reduce clinical errors[AHA]. TS incorporates SBAR for clinicians to communicate their concerns about a patient using a critical-skills conversation technique[Glu16]. If the team is used to speaking in an SBAR format, then vital information will not be missed; it will require a clinician's immediate attention and action[INH18]. Also prepare the staff in improving situational awareness by conducting time-outs, pre-huddles and debriefs. Safety awareness will increase and make all staff members more safety-consciousness about the patient conditions, equipment usage and collecting/sharing detailed information to all staff or 12 FINAL PROJECT - CASE STUDY family[INI2][AHR]. Four hospitals who use TS shown to improve their patient safety culture and increase teamwork attitudes[Gal12]. Another patient safety survey was conducted in Operating Room to get data about trainee reactions, learning, and behaviors in the OR, and outcome measures and it resulted that all levels received positive outcomes after implementing TeamSTEPPS[TJC10]. To ensure the communication and teamwork strategy is improving a yearly HSOPS should be performed in the department. Once results are finalized, then the information should be shared with all the staff members. The supervisors and average staff members should receive feedback from the report on the areas that need improvement and places they are doing well[Cam18]. Another way to measure is by using the IHI Improvement Capability Self-Assessment Tool. This assessment uses six key areas such as leadership improvement, results, resources, workforce staffing, data infrastructure and knowledge/competence[IHI1]. Using this will raise awareness of the areas of strengths and weakness; understand current improvement capability; and evaluate improvement efforts[IHI1]. Furthermore, to check the quality assurance then the leadership can conduct spot checks or simulate possible adverse events to see how the staff performance[INI3]. Lastly, if one person is designated as the patient safety champion or patient safety representative, then that person would teach, monitor and evaluate the patient safety culture of the department. They will be able to oversee possible barriers and develop strategies to help improve communication and team building[AHR1]. 13 FINAL PROJECT - CASE STUDY Each action plan should state explicitly in how the process will be measured and be monitored. Without a mission or vision, the team might be confused. The method that should be measured are staff trained, inspection results, and near-miss/adverse reports submitted and patient surveys data. If an adverse event arises then a Root Cause Analyze to understand what happened. The organization needs to embrace a culture of safety and not the team members be fearful of reporting an event. The hospital management needs to support their staff in training and providing adequate resources. The staff members have a responsibility to the patient and provide the highest-quality of care. 14 FINAL PROJECT - CASE STUDY • Developed a right­sided pneumothorax while playing soccer 1215 • Coach transported him to the Union Hospital Emergency Department 1225 • Triaged immediately due to his shortness of breath 1250 1300 • • • • • • • • 1300-1345 • • 1345 Seen by the emergency room doctor Chest film confirmed a right lower­lobe pneumothorax Doctor ordered a thoracotomy insertion tray As soon as the equipment was provided at the bedside, the nurse inserted the chest tube into Paul’s left side As time was of the essence, no consent was signed and a time out Chest tube insertion; no improvement in Paul’s shortness of breath. At this time, the nurse informed the physician that the chest tube had been inserted on the wrong side. Paul was becoming increasingly agitated and the physician mentioned to Paul what had happened. The nurse noted in Paul’s record that an incident report was filed for the wrong­side insertion Emergency physician attempted to have Paul admitted as an inpatient to Union Hospital so that the reinsertion could be done in the operating room • The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported and admitted to Jefferson Memorial, five minutes away. • The unit secretary had just returned from taking a late lunch break and did not see the transfer order • The nurse was admitting another patient to the emergency department. • The emergency physician, after writing Paul’s transfer orders, was now dealing with a 1345-1430 serious motor vehicle injury patient. • Paul oxygenation status continued to decompensate and he lost consciousness. • Nurse went to reassess Paul, he had expired 1430 Fi...
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  • Summer '18
  • Milestone, Patient safety, Patient Safety Systems

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