NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal
Student Name Capella University NURS-FPX 6016 Quality Improvement of Inter-professional Care Prof. Name Date Data Analysis and Quality Improvement Initative Proposal Good morning everyone. The topic for today’s presentation is data analysis and quality improvement initiative proposal on a health care issue that will be discussed throughout the presentation. It is the primary responsibility of healthcare professionals to provide quality care to their patients and work together to improve patient safety. To fulfill this essential duty it is significant for a healthcare organization to promote interprofessional collaboration among the employees, ensure effective leadership styles are utilized and healthcare workers are encouraged to incorporate evidence-based strategies in their practices. For this purpose and improvement of quality, leaders, and management of any healthcare organization plays an important role in successfully implementing the QI initiatives and achieving desirable outcomes. This presentation is based on a similar QI initiative that is proposed for the Vila Health facility where an incidence of adverse drug events provoked the management and other stakeholders to take effective interventions to preserve patients’ safety in terms of medication. Health Care Problem –Adverse Drug Events (ADEs) Adverse drug events are defined as those incidences where a patient is harmed due to exposure to a medication or because of a medication error that occurred due to poor quality of care. To understand it better, medication errors that occur at any stage of the medication process from prescription to administration, can lead to undesirable harm to the patients (Patient Safety Network AHRQ, 2019). Research states that the high-risk population encounters adverse drug events in elderly patients as they have multiple comorbidities for which several medication regimens are followed which can lead to adverse drug reactions or medication errors (Choi et al., 2022). Further study concluded that about 16-18 patients from 100 patients face various ADEs, which increase the mortality rate between 8.8-9.5% (Sahilu et al., 2020) and approximately 50% of these events are avoidable (Ersulo et al., 2022). Adverse drug events are not only harmful to the physical health of the patients but they also impact the finances of the hospitals. Research indicates that around $5.6 million is spent annually on ADEs by various hospitals in the US (Choi et al., 2022). Hence this is also an eye-opening challenge of adverse drug events and requires extensive efforts from the hospital management to initiate a quality improvement plan for safe practices and reduction in the costs associated with ADEs. A report from the patient safety and quality department of the Vila Health facility that recorded adverse drug events in the year 2021 to 2022 is presented in this presentation. Analysis of Dashboard Metrics Related to ADEs The statistical dashboard of Vila Health facility considered five major metrics to prepare this safety and quality report. The metrics are The quality of the data available is helpful in that the number of patients encountering adverse drug events has minimally reduced between both years however, the risk factors associated remained the same. The concerning point concluded from this data is the increasing length of stay and a significant increase in the readmissions rate. Although death incidences have decreased, leadership is still required to take quality improvement initiatives to further improve the results and ensure patients’ safety. These outcomes are concerning for the stakeholders of Vila Health facility – the patients, nurses, doctors, leaders, and policymakers. NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal Increased rate of readmissions is one of the major concerns as it is harmful to patients’ health as well as puts a financial burden on the hospitals. According to research, the Hospital Readmissions Reduction Program (HRRP) which was established by Patient Protection and Affordable Care Act, puts a hefty penalty by reducing Medicare expenses on the hospitals which have greater readmission rates. The purpose of this program is to reduce readmissions, minimize hospital costs associated and improve patients’ safety (Gai & Pachamanova, 2019). Thus hospitals need to improve communication and coordination among healthcare professionals to perform practices that are in favor of patients’ safety (Centers for Medicare and Medicaid Services, 2023). Another concern is the increased length of stay. A study identifies that most of the ADEs which result in increased length of stay are preventable and targeting those patients with an extended hospital stay due to preventable adverse events is an important action for stakeholders (Ersulo et al., 2022). These pieces of evidence are advocating the need for solutions and a quality improvement initiative. Outlining Quality Improvement Initiative Leadership plays an important role in encouraging employees to work for better patient outcomes and improve the quality of care. The quality improvement initiative proposed against adverse drug events includes three major strategies a) initiation of technologies for the overall medication process, b) constant professional training is recommended for healthcare professionals, and c) appropriate use of hands-off methods. Technology-Assisted Medication Process Adverse events related to medications can occur at any stage of the medication process (prescribing- administering), hence the introduction of technologies like computerized physician order entry (CPOE), electronic health information, and machine-readable coded systems are essential at every stage for correct prescription, right drug preparation and dispensing as well as right administration (Hajesmaeel Gohari et al., 2020; Schneider, 2018). The introduction of some of these technologies in Vila Health will reduce the discrepancies between the medications which are prescribed and administered. Moreover, this will act as a warning system for healthcare professionals before committing a malpractice action. Continuous Professional Training Research on the implementation of medication safety programs resulted that training related to medication safety improves the knowledge of healthcare professionals, increases their confidence, encourages positive behavior, and assists them in using the knowledge in their practices (Khalil & Lee, 2018). Continuous professional training also helps managers to assess the clinical competencies of healthcare professionals and take appropriate actions for improvement so that patient safety is ensured. Proper Hands-off Handover/hands-off is a process where the exchange of information and responsibility takes place between healthcare professionals. Proper hands-off is important
NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation
Student Name Capella University NURS-FPX 6016 Quality Improvement of Inter-professional Care Prof. Name Date Analyze a Current Quality Improvement Initiative Hospitals around the world face several healthcare issues which need some quality improvement (QI) initiatives so that effective healthcare is provided and positive patient outcomes are achieved. A similar QI initiative related to adverse drug events (ADEs) is established for the Vila Health facility. In a study, researchers concluded that out of 100 patients, 16-18 encounter adverse events related to the drugs. Moreover, these ADEs significantly cause multiple complications for the patients which can ultimately lead to an increased mortality rate (8.8- 9.5%) (Sahilu et al., 2020). Another study conducted in two tertiary care hospitals estimated that the costs associated with ADEs around $5.6 million annually (Choi et al., 2022). Further research indicates that adverse drug events are found in about ¼ of the patients. It is concluded that the majority of these ADEs are avoidable and indicates that there are chances to improve patients’ safety (Ersulo et al., 2022). NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation These sources of evidence advocate the need for quality improvement initiatives to ensure medication safety as well as improve patients’ outcomes. The quality improvement plan established for Vila Health facility was implemented after the incidence of wrong administration of sound-alike drug as mentioned in assessment 1 (the nurse administered Metoprolol to the patient instead of Metoclopramide which significantly decreased the patient’s blood pressure eventually causing mortality). This QI plan is subdivided into two essential parts – training and education for healthcare professionals and the establishment of organizational policies of zero tolerance against medication negligence. Although these two approaches assist the Vila Health facility’s staff and administration to create medication safety guidelines and interventions to promote a safety culture within the workplace, this initiative has a drawback that it does not address the issue of underreporting of adverse drug events. Moreover, the concern of staff shortage which is one of the most common risk factors for unsafe medication practices is not discussed in the quality improvement plan. Evaluation of the Success of the Quality Improvement Initiative Every improvement plan or initiative requires monitoring and evaluation to measure the success or failure of the plan. Hence the administration of Vila Health facility also evaluated the QI initiative implemented in their hospital. According to the Agency for Healthcare Research and Quality (AHRQ), the three areas of evaluation of any QI initiative are The success of the QI initiative implemented at the Vila Health facility is based on above mentioned key indicators. This analysis is based on the number of patients admitted to a healthcare facility and the participants included in the implementation plan like nurses, doctors, pharmacists, and patients. It is evaluated that the two approaches of the QI initiative have significant positive impacts on the patient safety outcome concerning adverse drug events. Firstly, it is noticed that due to interprofessional education, healthcare professionals are working collaboratively to improve medication practices. The adherence to the education guidelines like appropriate prescribing, dispensing, and rights of medication administration framework significantly increased. The data collected revealed that from 50% of healthcare workers showing adherence, it raised to approximately 88% of healthcare workers following the standard guidelines. Moreover, the zero-tolerance policy against medication negligence enabled healthcare professionals to be vigilant during the entire medication process. This was evident by the reduced number of drug-related adverse events from 10/100 patients to 3/100 patients. Additionally, a survey collected from patients identified that 85% of patients responded with improved experiences related to the quality of care. Interprofessional Perspectives and Actions Implementation of any quality improvement initiative requires a task force to collaboratively work together so that successful outcomes are obtained. Researchers identify that the frontline workforce is primarily responsible for effective collaboration with personnel from multiple professions (Brugman et al., 2022). Hence as frontline staff, nurses have this responsibility. The interprofessional team involved in the quality improvement plan at Vila Health facility comprised nurses, nurse managers, nurse educators, the quality control department, and the administration/policymakers of the hospital. The role played by each of the categories of the interprofessional team is The uncertain information of this analysis is whether there were any initiatives were taken for continuous monitoring of the adverse events. Moreover, no information is provided against the major risk factor of medication malpractices which is overburdened nurses due to a shortage of staff. Additional Recommendations The additional recommendation for improved outcomes of quality improvement initiatives is to use continuous monitoring using the PDSA cycle for effective outcomes. Moreover, clinical audits are essential for the continuous monitoring and sustainability of QI initiatives. Continuous Quality Improvement (CQI) using the PDSA cycle: The PDSA model is the most common model used in healthcare systems for the continuous improvement of quality care. The purpose of the PDSA cycle is to continuously collect data, plan interventions for smaller groups and use that data for revising interventions as per the need (Knudsen et al., 2019). The four parts of PDSA include Clinical audits: A clinical audit is a tool recommended for QI in clinical practices. It plays a significant role in improving outcomes and patients’ safety. The cycle of clinical audit involves analyzing practices, establishing standards, comparing the practices with the set standards, and finally improvising the practices with new strategies (Alyacoubi et al., 2021). Therefore it is recommended to have frequent clinical audits for observing staff’s practices related to medication safety and upon the data collected further improvements in the practices can be initiated. There are various positives and negatives of these recommendations. The positives are that these recommendations will improve patient outcomes, help in continuous monitoring of setbacks, and enables healthcare professionals to realize the loopholes of the practices to improve timely. However, the cons of these recommendations are the establishment of an audit team will require more human resources thus adding an extra task for hospital administration. Moreover, the PDSA cycle being a continuous process is time-consuming which eventually is an
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Student Name Capella University NURS-FPX 6016 Quality Improvement of Inter-professional Care Prof. Name Date Adverse Event or Near-Miss Incident Analysis Hospitals commonly encounter various adverse events every day. These events can be near-miss or actual events that may have negative impacts on the patients, the hospital’s workforce as well as on hospital’s reputation. The study defines adverse events as those preventable incidences due to medical treatment or because of the actions of healthcare professionals, which causes unfavorable outcomes for patients’ safety (Liukka et al., 2020) further study describes near-miss events as those incidents which have not caused the harm yet because of any preventive intervention taken already before the harmful action could happen (Lee, 2021). The prevalence of adverse events in healthcare settings approximately ranges from 2.9% to 16.6%, out of these the preventable errors range from 1.0% to 8.6% (Zanetti et al., 2021). There is research conducted to analyze that adverse events can be life-threatening as well. It is estimated that above 250,000 patients encounter adverse events out of which 100,000 face mortality (Skelly et al., 2022). There are several kinds of adverse events that occur in healthcare settings. The purpose of this analysis report is to discuss adverse drug events (ADE) of a case that happened in the Adult Medical Unit at Vila Health Facility. Moreover, some of the strategies will be presented to eradicate these events. NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis Mrs. John, a 75-year-old female patient is admitted to the hospital because of Acute Gastroenteritis. She is in the ward for the last two days and is receiving regular treatment. Yesterday, nurse Helen was assigned to the patient. She had a very busy shift because of low staffing and she was assigned 10 patients at a time. During her shift, Mrs. John complaint of epigastric pain and feeling nauseated. Helen immediately informed the doctor about the patient’s complaint and probed to prescribe any medication. Doctor Gen entered the medication in the system and asked the nurse to give Metoclopramide 10mg to the patient from the stock cabinet until the drug arrives at the pharmacy. Helen being understaffed and overworked took out Metoprolol instead of Metoclopramide from the stock cupboard and without carefully checking the label, she administered the medication to the patient. After 30 minutes, Mrs. John’s caretaker rushed to the nursing counter and shouted that her patient is feeling dizzy and had an irregular breathing pattern. Upon arriving at the patient’s room, the nursing team and doctors found that the patient is unconscious and her vital signs are deranged. Immediate code blue was announced. All healthcare professionals tried their best to save the patient but she ended up losing her life. Nurse Helen was called by the nursing supervisor to investigate the issue. Moreover, the patient’s family was informed about this undesirable event which led them to file legal cases against the nursing staff as well as the hospital. This was a challenging event that provoked nurses and the hospital administration to further examine adverse drug events in their hospital setting to ensure patient safety and quality improvement (QI). Implications for the Stakeholders Every issue that a healthcare facility faces requires a team of multi-professional personnel and various stakeholders to plan, derive solutions, make decisions, support financially, and implement those solutions to ensure patients’ safety and quality improvement. In this case, Mrs. John and her family are the foremost stakeholders which were negatively impacted by this adverse event. In the second line, the affected stakeholder is the nurse who was involved in this adverse event and lastly, the hospital and hospital’s administration, and directors are involved. Negative patient outcomes have various implications for healthcare providers, hospital administration, and policymakers. It is the primary responsibility of doctors and nurses to provide quality care to their patients using standardized clinical practices, especially regarding medication safety. On the other hand, nurse leaders should ensure that every team member is fully equipped with the best-practice knowledge of medication safety. Moreover, administration and policymakers are required to establish policies for medication safety ensuring patients’ safety is not compromised (Abdulrouf et al., 2019). Various assumptions on which this analysis is based are Therefore, it is significant for hospitals like Vila Health facility to take appropriate measures to reduce these adverse events. For this purpose, some of the actions and technologies will be discussed later in this analysis. Missed Steps, Protocol Deviations, and Knowledge Gaps Analysis The case presented above gives evidence that negligence related to medication administration can lead to severe complications for patients. A study showed that the prevalence of ADE ranges from 16.3% to 18.3% per 100 patients. Furthermore, these adverse drug events can cause many significant harms to the patient with 1.4% of life-threatening harm and a mortality rate is 8.8% to 9.5% cases out of 100,000 patients (Sahilu et al., 2020). This evidence reveals the importance of preventing drug-related errors in hospitals to preserve patients’ safety and improve care. Some of the missed steps and protocol deviations identified in this situation are: NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis To ensure patient safety in terms of preventing adverse drug events, a framework is established which is called rights of medication. Research recognizes that because of nurses’ non-adherence to the rights of medication, 32.6% of drug-related errors are due to incorrect administration of drugs (Salami et al., 2019). These five “R” (rights) are the right patient, the right drug, the right dose, the right time, and the right route (Jones & Treiber, 2018). Nurses must be equipped with the knowledge and appropriate implementation of this framework. Nursing leaders are expected to promote the concept and the administration should develop policies against these malpractices. In this case, if there is some missing information like Metoclopramide is a basic medication then why Helen couldn’t wait for the pharmacy to dispense the drug? Why the doctor was not aware of the policy of verbal orders? Why the short-staffed unit was not supervised