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Case Study – Enhancing Quality and Safety

Perkins

Case Study – Enhancing Quality and Safety

Explain factors leading to a specific patient safety risk focusing on medication administration.

In the case scenario, a patient was admitted to the healthcare facility on the 22nd of November, 2020, with a 5mg Coumadin one-time medication order and another order for the patient’s INR to be checked. The check-up was not done because the patient was on dialysis at the time it was to be done; also, the nurse on duty did not know that the lab test was not done. On the 23rd of the same month, the nurse who signed off the alert noted that there was no Coumadin and INR 2.2. On the 24th, as the lab check-off was done, it was discovered that there was no order for Coumadin, yet the notification made on the 23rd showed that the patient was given 5mg Coumadin.

Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.

One of the nurses was reading the omission and began an immediate investigation. The lab work was done, and the INR was recorded as 1.2. An order was given for 3 days of 6mg Coumadin. The resident was administered with the 6mg Coumadin. After some time, the supervisor summoned the staff that had done the investigation and notified him that the patient’s oxygen levels had declined. The patient was given oxygen, though her level of oxygen failed to improve. The patient was hooked to a Heparin drip after diagnosis of a pulmonary embolism. The patient was then stabilized.

The primary care physician noted that the patient had a history of pulmonary embolism, yet the charts did not indicate that the patient had a filter. The physician also informed the staff that removing the patient from Coumadin, even for dentistry work or any other reason, should be subjected to close monitoring. If the patient’s INR dropped, the standard care practice was to start IV anticoagulant until the INR levels went up again. Coumadin takes 5 to 7 days, hence the importance of an anticoagulant bridge when the level of INR is at 1.5 (Schleifer & Vannatta, 2019).

The healthcare facility must have all books reviewed to ensure no other patient was affected. The red Coumadin book review should be done on a daily basis. The supervisors will be alerted and given a list of INR tests during the weekends. Every staff will receive education on the importance of documenting the flow record of Coumadin. Every staff member should be conscious of the possibility of a medication error when administering Coumadin and ensure a valid order is in place if a patient previously taking Coumadin is on temporary hold of the drug. The Coumadin book has to be updated with every new order. The INR checks also need to increase the frequency when a patient is on antibiotics. The staff will be issued a standard alert stating that orders for requested labs are checked for Coumadin. The order will require that the staff indicate a Yes or No to depict whether Coumadin is present.

Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.

Administration of drugs is a medication error subset and can be an area where the most problematic challenges occur. Medication errors are costly to the safety of the patient and the financial implications that come with them (Bravo, Cochran, & Barrett, 2016). Research shows that every time a medication error is intercepted, the amount saved is $7,000 (Lippincott Nursing Center, n.d). Some of the main causes of medication errors are interruptions and distractions. Distractions and interruptions that occur during the delivery of drugs are common contributors to medication errors (Cloete, 2015). There are two strategies, among others, that can be implemented in lowering the rates of medication errors in inpatients, as was the case in the scenario discussed herein: a programmed script that raises awareness on why it is important to have no interruption during medication delivery and the implementation of the 3D protocol in the hospital policies.

Creating a specific script to address any interruptions will help reduce interruptions by staff, family, and friends of the patient (Hayes, Jackson, Davidson, & Power, 2015). Clear language assuring the patient that their concerns and needs are of utmost importance is important. The nurse should set guidelines with the patient’s family and friends regarding the need for them to be quiet as drug medication takes place and the need for utter concentration when performing procedures. When patients and families are incorporated into medication protocol, the patient’s safety will be enhanced, and a reduction in medication errors becomes possible.

The 3Ds stand for Deflecting, Deferring, and Determining. When a nurse is interrupted while delivering medication or performing a procedure, the nurse quickly assesses the situation’s urgency level. The nurse then makes a decision to proceed with either deflecting to modify or manage the need for it to cease being an issue, deferring the issue while still handling the current need later, or determining whether someone else is capable of safely assessing and managing the need.

Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.

The patient and kin are the first stakeholders who need to be made aware of the priorities when it comes to delivering medication or performing procedures. The patient and the kin should be educated on why they should not interrupt the nurse as she performs her duties. The patient and kin should also be encouraged to update all their relevant illness records in their PHRs. The physician, the next stakeholder, must enter the correct information in the patient’s EHR to avoid medication errors. Where medication is handwritten, the physician needs to do so in legible and clear handwriting for the nursing staff and the pharmacist. The third stakeholders are the nursing and hospital staff, who are supposed to enter timely and accurate patient information every time they attend to the patient to avoid any errors.

References

Bravo, K., Cochran, G., & Barrett, R. (2016). Nursing strategies to increase medication safety in inpatient settings. Journal of Nursing Care Quality, 31(4), 335-341.

Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1).

Hayes, C., Jackson, D., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. Journal of Clinical Nursing, 24(21-22), 3063-3076.

Lippincott Nursing Center (n.d). Nursing Strategies to Increase Medication Safety in Inpatient Settings. https://www.nursingcenter.com/ce_articleprint?an=00001786-201610000-00006

Schleifer, R., & Vannatta, J. B. (2019). Mistakes in Medicine. In Literature and Medicine (pp. 183-195). Palgrave Macmillan, Cham.

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Question 

Case Study – Enhancing Quality and Safety

For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Enhancing Quality and Safety

Healthcare organizations and professionals strive to create safe environments for patients however, due to the complexity of the healthcare system, maintaining safety can be a challenge. Since nurses comprise the largest group of healthcare professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States (Kohn et al., 2000), and 210,000–440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improve patient safety, and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.
You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

Demonstration of Proficiency

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in healthcare settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

Scenario

Consider a previous experience or hypothetical situation pertaining to medication errors, and consider how the error could have been prevented or alleviated with the use of evidence-based guidelines.

Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care.

For this assessment:

Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.

Instructions

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks in a healthcare setting of your choice. You will do this by exploring the professional guidelines and best practices from organizations such as QSEN and the IOM for improving and maintaining patient safety in health care settings. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance the quality of care and promote medication administration safety in the context of your chosen healthcare setting.

Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide.

Please study the scoring guide carefully so that you know what is needed for a distinguished score.

Additional Requirements

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