MSN-FP6016: Adverse Event or Near Miss Analysis
Adverse Event or Near Miss Analysis
The healthcare sector is a challenging field of work where the nurses and physicians must observe high degrees of professionalism. Minimal errors in the nursing practice can result in severe damages to the patient and, in extreme cases, irreversible health implications. The nursing code of ethics recommends that the professionals exercise a high level of work principles to ensure the patients' quality and safety under their care. The nurses and clinical officers take an oath that binds them to the practice and compels them to always promote quality health. The principles of work in the field guide the practicians on observing professionalism and being assured of the best outcome inpatient care. The minimal errors experienced in practice often threaten the patients' lives as they develop complications caused by the medical staff and not the underlying condition that brought them to the hospital.
Evaluation of missed steps and protocol deviation
Nurses operating in intensive care units must ensure the patients are safe and free from any possible harm. Intensive care requires the nurses to be vigilant and observe every form of caution while taking care of them. A nurse failed to raise the bed rails as recommended of them after every visit. The nurse had finished feeding critically ill patients and followed every step to ensure the patient as well. Unfortunately, she forgot to raise the best side rails, which prevent the patient from falling. When the nurse left to check on other patients as obligated to shift, the patient tried to move and experienced a severe fall. The patient endured injuries and broke her arm in the process. The case indicates a scenario where a nurse failed to follow protocol to ensure the patient was safe from the bed position (Ghooi, Bhosale, Wadhwani, Divate & Divate, 2016). Many questions were raised following the incident. The patients' family raised a suit terming the event as carelessness on the part of the staff. The patient endured other injuries and complications apart from the specific condition that brought him to seek medical attention at the facility.
The implications of adverse events
The events following the patient’s broken arm were critical to the nursing profession. The nurses are always reminded to ensure the patients are safe before they can leave to the nest client. When administering medication or attending to a patient in anyways, the bed rails are always adjusted to give room for the health practitioner to easily access the patient. The context makes it difficult to come to terms with the idea that a bed rail was not adjusted back to its right position to enhance the patient's safety. The case was ruled as carelessness on the part of the nurse attending to the patient. The patient endured other injuries that were not there when he was brought in for treatment at the facility. The nurse failed to follow protocol, and the incident forced her to endure the punishment from the hospital administration. The nurse faced disciplinary charges as the patient and his family sued her for negligence and poor patient attendance in critical condition. The situation resulted in an urgent convention of the nurses of their shifts to train and educate them on the important safety measures they need to observe while handling patients in the facility. The part of adjusting the bed rails is always stated in the safety notes, especially when dealing with patients in critical conditions or the elderly who are vulnerable to fall.
Quality improvement technologies
Technology has come to enhance medical facilities and operations. The intranet of things in the medical setting helps eliminate the errors in the medical setting related to human error and negligence. The hospital beds are connected to system software that allows nurses to adjust the patient beds from a remote location. The patient can adjust the bed and bed rails from the button installed on the bedside (Mohamed, 2019). Simultaneously, a nurse can adjust the bed or its rail from a remote location using the connected hospital tablets. The system software is also designed to remind a nurse that the bed rails are not adjusted to the right position. The warning alert on the system identifies the patient at risk, the room number, and points the dangers of the issue.
The technology improvement technology has been adopted in various health facilities worldwide and continues to become a trend in many other hospitals. Healthcare facilities identify the need for such technologies to help reduce the errors experienced in these facilities. The desire for patient safety further compels the health sector to link with the technology experts to make more systems that enhance patients' safety and assure them of quality care (Julian, Arthur, Anita & Ioannis, 2016). The system software linked to the bed ensures the patient is safe at all times and will keep sending reminders to the nurse until necessary action is taken to adjust the bed to the right position. Audio output is also enabled to alert the nurse through the tablet that there is an urgent concern. The experts appreciate that the alarm alerts on the devices can cause side effects for both the patients and caregivers. As a result, they dedicate their innovation to creating a system that minimizes the false alerts and increase the positive elements associated with the technology.
Relevant metrics of the adverse event
According to Balaguera et al. (2017), at least 70% of patients in hospitals in the United States fall. The population I tallied to read between 2.6 and 17.1 per every 1000 patients. The incidences cause injuries and, in other cases, extreme harm. In most instances, the issue is ruled to be negligence on the part of the medical staff. There are limited instances when the fall can be attributed to the carelessness of the patient. Unfortunately, even the cases where the patient can easily be blamed for the fall are attributed to the nurse's negligence or attending practitioner. The fall has become a severe issue within the medical sector and calls for urgent intervention. Technology experts have worked their ways to establish the best response to such cases by developing innovative medical technology to improve healthcare delivery and patient safety.
Quality improvement initiative
Quality improvement is a necessary approach within the healthcare sector. Every health facility is determined to ensure their patients are safe and receive quality treatment in the facility. As a result, it is recommended to always have continuous training and education of the nurses and other medical staff to remind them of the need to always observe the patients' safety first and conduct practices that promote quality care. The continuous training promotes a culture of learning within the facility and helps the staff appreciate the need for continuous improvement (Janya et al., 2018). A feedback process system should also be implemented in the facility to help make improvements often. The supervisors or nurse leader should always monitor their teams' activities and point out the areas they feel need to be adjusted. The feedback points to both the negative and positive elements in practice. It helps make the negative issues reformed while the positive ones are upheld and acknowledged as best practice. A checklist can also be issued to the nurses to guide them on their patients' safety measures. The checklist can be digitized and installed in the tablets for the nurses to use while reviewing their patients' status. The checklist can prompt questions on safety, including the bed's position, the bed rails, and the accessibility of the alarm on the bedside for the patient, among others.
The nursing field is associated with strict guidelines to ensure safety and quality care for the patient. The incident identified in the study appreciates how minimal errors in the practice can result in severe consequences. Nurses can be sued for negligence in case of such events and their operating licenses canceled. The hospital can also be sued for negligence and charged with causing harm to the patient. The incident identifies the need to be cautious when handling patients, especially those in intensive care units and the elderly. The safety checklist can be the best appropriate measure taken to ensure such incidents and other typical errors are reduced to enhance the patients' safety at all times. A culture of learning can initiate a continuous improvement initiative to help the nurses improve their safety and quality care skills.
Balaguera, H. U., Wise, D., Ng, C. Y., Tso, H. W., Chiang, W. L., Hutchinson, A. M., Galvin, T., Hilborne, L., Hoffman, C., Huang, C. C., & Wang, C. J. (2017). Using a Medical Intranet of Things System to Prevent Bed Falls in an Acute Care Hospital: A Pilot Study. Journal of medical Internet research, 19(5), e150. https://doi.org/10.2196/jmir.7131
Ghooi, R. B., Bhosale, N., Wadhwani, R., Divate, P., & Divate, U. (2016). Assessment and classification of protocol deviations. Perspectives in clinical research, 7(3), 132–136. https://doi.org/10.4103/2229-3485.184817
Hamm, Julian & Money, Arthur & Atwal, Anita & Paraskevopoulos, Ioannis. (2016). Fall Prevention Intervention Technologies: A Conceptual Framework and Survey of the State of the Art. Journal of Biomedical Informatics. 59. 10.1016/j.jbi.2015.12.013.
Khalifa, Mohamed. (2019). Improving Patient Safety by Reducing Falls in Hospitals Among the Elderly: A Review of Successful Strategies. Studies in health technology and informatics. 262. 340. 10.3233/SHTI190088.
Mccalman, Janya & Bailie, Ross & Bainbridge, Roxanne & McPhail-Bell, Karen & Percival, Nikki & Askew, Deborah & Fagan, Ruth & Tsey, Komla. (2018). Continuous Quality Improvement and Comprehensive Primary Health Care: A Systems Framework to Improve Service Quality and Health Outcomes. Frontiers in Public Health. 6. 10.3389/fpubh.2018.00076.