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Unformatted text preview: Running head: FINAL MILESTONE 1 7-1 Final Project Submission: Error Analysis and Recommendations Paper Emily L Wheeler IHP – 315 Patient Safety Southern New Hampshire University FINAL MILESTONE 2 7-1 Final Project Submission: Error Analysis and Recommendations Paper I chose the case study about the twenty-year-old male patient named Paul. Paul was brought in to the Union Hospital emergency room for a sports injury by his soccer coach. Paul was diagnosed with a right-lower lobe pneumothorax. A few critical occurrences occurred during his care that ultimately resulted in Paul’s death. A chest tube was inserted to his left lung instead of his right and without a timeout before insertion. There was no consent form signed. Physician sent a transport order to Jefferson Memorial a nearby hospital, and the order wasn’t received in time. Secretary and emergency room nurse at Jefferson Memorial were both preoccupied. The emergency room doctor from the Union hospital did not check to make sure the other hospital had received his orders for immediate surgery. Root Cause Analysis: Timeline At 1215: Developed a right lower-lobe pneumothorax while playing soccer. At 1225: Coach transported Paul to the Union Hospital Emergency Department. Arrived at 1250: Paul was triaged quickly due to his shortness of breath. At 1300: Seen by the emergency room doctor. Chest film confirmed a right lower-lobe pneumothorax. The 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. Time was limited, and no consent was signed, and nurse didn’t call for a time out or wait for doctor’s orders. At 1300-1345: Paul had the chest tube inserted; no improvement in Paul’s shortness of breath. At that 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 but did not explain in detail to Paul what had happened. The nurse noted in Paul’s record that an incident FINAL MILESTONE 3 report was filed for the wrong-side insertion. Emergency physician ordered for Paul to be admitted as inpatient to Union Hospital to have chest tube immediately placed in his right side. At 1345: The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported to Jefferson Memorial right away. At 1345-1430: The unit secretary had just returned from taking a late lunch and did not see the transfer order. The E.R nurse was taking another patient to the emergency department. The emergency physician, who wrote Paul’s transfer orders was now dealing with a serious motor vehicle injury patient but, did not follow up or direct someone to make sure Paul was being picked up for transportation; and keeping communication with the other hospital and EMS. Paul’s oxygenation stats continued to drop, and he lost consciousness. At 1430: Nurse went to reassess Paul, and he had already expired. (SNHU, 2018) I added a chart of the timeline below. FINAL MILESTONE 4 FINAL MILESTONE 5 Root Cause Analysis: Factors A couple of factors that directly contributed to the death of Paul. One of the factors was from the doctor who ordered a thoracotomy insertion tray and did not order the nurse to perform the procedure. The nurse was in the wrong for performing the procedure unaccompanied and without doctor orders. The doctor should have been the one to do the procedure. The health care providers did not receive consent to treat Paul. There wasn’t any education given, alternative treatments, or risks of performing the procedure. “A chest tube may be inserted at the bedside, in procedure room, or in the surgical suite. Health care providers often assist physicians in the insertion and removal of a closed chest tube drainage system” (Doyle & McCutcheon, 2019). The nurse neglected to check for two identifiers and explain the procedure. Insertion of a chest tube is a sterile procedure, which we do not know if the nurse took those precautions. Before any invasive procedure is performed there must be a “time out.” “The Universal Protocol requires three separate steps: the proper preoperative identification of the patient by the three members of the team (surgeon, anesthesiologist, nurse), marking of the operative site, and a final "time out" just prior to the surgery or procedure regardless of where it is being performed” (Feldman, 2008). Following a chest tube insertion there much be an x-ray done to make sure placement is correct. “With respect to the "content" of a time out, the Joint Commission requires confirmation of the correct patient, correct side and site, agreement on the procedure to be performed, correct patient position, and availability of needed equipment/supplies/implants… time outs are mandated by the Joint Commission, and hospitals have an obligation to ensure they are being performed” (Feldman, 2008). FINAL MILESTONE 6 Another factor that caused devastating complications was the doctor or nurse didn’t ensure that the hospital the doctor was transferring Paul to had received his orders. Then the doctor became preoccupied with motor vehicle accident victims. Communication was not used the way it should have been used during this entire situation. Patient Safety Strategies: Recommendations I recommend that the hospital needs to create a plan and procedure for staff to follow when an emergency invasive procedure needs to be done. For example, using check lists and the time out method before starting the procedure which, the joint commission has already mandated. Using check lists have been proven to reduce errors. “A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement” (Checklists | AHRQ Patient Safety Network. 2019). Creating a plan and check list for patient transfers. If Paul would have been transferred to the other hospital sooner, he may have not died. “To better support effective transfers from the emergency department the American College of Emergency Physicians outlined several recommendations in a 2012 report on improving care coordination. The following recommendations are relevant to the Emergency Department Transfer Communication Measure Set: Enhance and promote training and education for all emergency department personnel regarding the importance of transitions of care and how to implement effective policies and procedures. Assess provider performance, with appropriate feedback, and provide training in communication skills as necessary. Work with emergency department information system FINAL MILESTONE 7 vendors to produce transition support tools and identify the components of a minimum data set for all transitions” ("Quality Improvement Toolkit for Emergency Department Transfer Communication Measures", 2019). Patient Safety Strategies: Measurement Having a risk management team is very important in all healthcare settings. People in this team keep a track record of errors and educate staff on errors that have or could occur. Implementing training to prevent the errors that occur. Creating a team that include physicians, administrators, nurses, and other healthcare team members to improve emergency department and hospital transfer communications. Including emergency department staff that know and understand how the department works. Assigning team members on each shift to oversee making sure all transfers go smoothly. Having risk management teams in different departments is crucial. They can keep tract of errors and find ways to preventing these errors by communicating with staff on the job and during staff meets. Prevention is key to keeping everyone safe and informed. Disclosure: Details “The purpose of reporting is to collect data on a broad range of events to detect systemic problems that can be altered to reduce the risk of patient harm. Most mandatory systems focus on serious injury to patients, but some also collect reports on incidents such as drug diversions, patient elopement, or fires in the operating room, which may not result in injury. In addressing the public’s “right to know” about facilities’ performance, mandatory systems tend to use state licensing authority to require that events are reported and hold facilities accountable by ensuring that incidents are investigated and that corrective actions are taken” (Weissman et al., 2005). FINAL MILESTONE 8 In this case study Paul’s family will need a detailed explanation for his death. The family needs to be informed of what, where, and when did these mistakes occur. Hospital needs to explain to the family of their rights and rights to legal counsel. How will the facility avoid a tragedy just as this in the future for other patient’s? “Disclosure of errors and adverse events is now endorsed by a broad array of organizations. Since 2001, the Joint Commission has required disclosure of unanticipated outcomes of care. In 2006, the National Quality Forum endorsed full disclosure of "serious unanticipated outcomes" as one of its 30 "safe practices" for health care. The disclosure safe practice includes standards for practitioners regarding the key components of disclosure. It also calls for health care organizations to create an environment conducive to disclosure by integrating risk management and patient safety activities and providing training and support for physicians. Ten states mandate disclosure of unanticipated outcomes to patients, and more than two-thirds of states have adopted laws that preclude some or all information contained in a practitioner's apology from being used in a malpractice lawsuit” ("Disclosure of Errors | AHRQ Patient Safety Network", 2019). The patient and family should be informed of what happened, how it happened, why it happened, and when it happened. Explained in detail of the events as they occurred, the mistakes, penalties, and corrective actions that will be put in place. Provoke family to ask questions. Family should also be informed of the steps the facility will take to prevent this error of occurring again. Rendering to §482.13 Condition of participation: Patient's rights is stated that “The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital's governing body must approve FINAL MILESTONE 9 and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee” ("eCFR — Code of Federal Regulations", 2019). The hospital must have all information in writing including, their decision, the outcome of the investigation, and all current dates from beginning to ending of the investigation. Disclosure: Method and Preparation Being involved with an error and having to disclose must be very troubling. To the healthcare provider or providers these errors are very personal. The things that come with this can include feeling guilt, devastated, self-blaming, and second-guessing one’s self. The provider must release control over the situation and information, which must be extremely hard. Recommendation for healthcare provider to become prepared for disclosing the error with the patient and family should include collecting their personal feelings and emotions. Talking with coworker’s who were involved. Investigating the mistake from start to finish so they can answer all questions and be able to give details. Being honest with their selves. Having a disclosure strategy should be in place. This topic should be taught in all training classes and I would recommend it be practiced by using role play. There is a strategy that the University of Michigan has been using called “communication-and-response.” This strategy focuses on disclosing the error and adverse proceedings as soon as possible and focusing on a proactive method. The University of Michigan and other institutions have seen a decline of malpractice lawsuits and litigation costs since they began using the “communication-and-response” strategy. “This model includes full disclosure of adverse events, appropriate investigations, implementation of systems to avoid recurrences, and rapid apology and financial compensation FINAL MILESTONE 10 when care is deemed unreasonable” ("Disclosure of Errors | AHRQ Patient Safety Network", 2019). Disclosure: Reporting Medical errors are not required to be reported to the Joint Commission. The Joint Commission can offer their support and knowledge to the hospital during a review. The Joint Commission can provide access to a patient safety specialist who has had experience in similar situations. Reporting to the Joint Commission shows everyone that they are promoting a culture of safety. It also shows the public the hospital’s message that they are doing everything they can to prevent negative patient safety events in the future. The Joint Commission states, “Standard LD.04.04.05, EP 7, requires each accredited hospital to define patient safety event for its own purposes and to communicate this definition throughout the hospital. This definition must encompass sentinel events as defined by The Joint Commission. An accredited hospital is encouraged to include in its definition events, incidents, and conditions in which no or only minor harm occurred to a patient. The hospital determines how it will respond to patient safety events that do not meet the definition of sentinel event.” ("Sentinel Events (SE)", 2016) “The Medical Staff (MS) Standard MS.05.01.01, EP 10, requires hospitals to include sentinel event data among the information used as a part of performance improvement activities to improve the quality of care, treatment, and services and patient safety. EP 11 of that standard requires that patient safety data is also used in those activities.” ("Sentinel Events (SE)", 2016) “In addition, Rights and Responsibilities of the Individual (RI) Standard RI.01.02.01RI.01.02.01, EP 21, requires an accredited hospital to inform the patient or surrogate decision-maker about unanticipated outcomes of the care, treatment, and services that relate to sentinel events as FINAL MILESTONE 11 defined by The Joint Commission. EP 22 of that standard specifies that the licensed independent practitioner who is responsible for managing the patient’s care, treatment, and services (or his or her designee) must inform the patient about unanticipated outcomes of care, treatment, and services that relate to sentinel events when the patient is not already aware of the occurrence or when further discussion is needed” ("Sentinel Events (SE)", 2016). Patient Safety Culture: Analysis “The latest hospital safety survey indicated categories of strength (positive response) were supervisor promoting patient safety at 75% and management support for patient safety at 70%. Weak areas were staffing at a survey positive response of just 25% and a low 15% positive response for hand-offs and transitions” (SNHU, 2019). Staffing and response for hand-offs and transitions need to be improved. If they are not improved many more tragedies like Paul’s death will occur. Patient Safety Culture: Outcome “A 2016 study in The BMJ found that medical mistakes are actually responsible for more than 250,000 deaths in the United States each year. If medical errors were classified as a cause of death – they currently aren't tracked as such – they would rank third on the list of deadliest conditions behind heart disease and cancer. Human error is to blame in most cases of medical mistakes and many of these problems begin as a simple miscommunication between members of the care team” ("SBAR Tool: Situation-Background-Assessment-Recommendation", 2019). The outcome for Paul was devastating and would not have ended that way if the facility had a stronger patient safety culture. If there had been enough staff onsite at that time the licensed professional, the physician would or should have placed the chest tube. The physician would know the correct steps and tests to be done before and after the procedure such as having FINAL MILESTONE 12 x-rays to check for correct placement. Having stronger communication could have also stopped this mistake. The physician did not instruct the nurse to perform this procedure. The nurse did not talk to the physician before placing a chest tube, nurse should have known this was not in their scope of practice. Patient Safety Culture: Recommendations “The latest hospital safety survey indicated categories of strength (positive response) were supervisor promoting patient safety at 75% and management support for patient safety at 70%. Weak areas were staffing at a survey positive response of just 25% and a low 15% positive response for hand-offs and transitions” (SNHU, 2019). Staffing and response for hand-offs and transitions need to be improved. There are several strategies that could be helpful such as TeamSTEPPS, SBAR, and collaborative staffing. Staffing is critical in healthcare. If there isn’t enough staff to correctly perform their jobs, then patients are in danger. A module that hospitals are using is called collaborative staffing. “Collaborative Staffing is a ground-up model that empowers employees to be part of the solution in deploying the workforce to ensure optimal patient coverage and minimize labor costs” (Kerfoot, 2019). “Differences in mortality rates across hospitals are well documented by several researchers. Literature on RNs' impact on hospital mortality rates is considerable. Prescott (1993) provides a comprehensive review of empirical evidence of the impact of nursing staff levels and mix on quality of patient care in hospitals. Much of the evidence came from regression analyses that used RNs as a share of total hospital nursing employment as an explanatory variable— essentially, a basic ''numbers" variable. Overall, she found substantial evidence linking RN staffing levels and mix to important mortality, length of stay, cost and morbidity outcomes. FINAL MILESTONE 13 While nurse staffing is not the only factor predictive of mortality outcome, it is an important one affecting the quality of hospital care” (Homes, Wunderlich, Sloan & Davis, 1996). SBAR is a great tool to safely to complete hand-offs and transitions. The survey presented only a 15% positive response for hand-offs and transitions. “The SBAR (SituationBackground-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition” ("SBAR Tool: SituationBackground-Assessment-Recommendation", 2019). “S = Situation (a concise statement of the problem), B = Background (pertinent and brief information related to the situation), A = Assessment (analysis and considerations of options — what you found/think), R = Recommendation (action requested/recommended — what you want)” ("SBAR Tool: Situation-Background-Assessment-Recommendation", 2019). SBAR is easily memorized and to recall. It is a solid tool for any discussion. It is crucially important to use during patient transfers. The emergency department physician that called to have Paul transferred would have made the communication clearer. This would have also prevented harm that had been done to Paul. Using SBAR is vital for collaboration of teamwork and a positive culture of safety. “Communication between health care personnel accounts for a major part of the information flow in ...
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