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Measurement: How will the strategy be measured so that medical staff can determine whether the strategy led to improved patient safety? In other words, what will the primary measure be? What types of data should be collected? 

 

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Contributing Factors

There are a variety of contributed factors that lead to the medical error. The first contributing factors that led to the medical error is the preoccupied and bustling state of the nurse while tending for a patient with congestive heart failure. The nurse did not read Ms. Viani’s file. Had the nurse invested time to look at and assess the patient and study the current management, the nurse would not have made the medication error of giving a second dose of Lasix that lowers the client’s potassium level causing disorientation leading to the fall incident. Furthermore, the nurse did not follow hospitalist’s instruction and administered the Lasix IV three hours after patient was hospitalized and blood work to check electrolytes was done before the Lasix IV. The Lasix IV was meant to be given right after patient’s admission followed by a lab test to check electrolytes one hour later. Another contributing factor is the formulation of the assumption by the hospitalist about the lab work up without checking with the rest of the health care team or with the patient when the blood was drawn led to the medication error. Lab should be ordered before the administration of the Lasix. It was a lack of communication among the hospitalist and the nurse. His order is generally accorded respect and without the proper verification, his order may go unchallenged by the assigned nurse. The physician did not review the directive and assumed Lasix IV was given before blood drawn. Mistakenly, ordered a second dose of IV Lasix that led to the incident that the patient experienced. Definitively, both the hospitalist and the nurse had weak communication skills and recordkeeping skills assuming all the instructions were followed in the order were directed. 

Casual Factor

The fact that the nurse was extremely busy at the time of the medical mistake and most likely did not double check her orders for Ms. Viani is one of the casual factors that contributed to the mishap. If she had reviewed the order, she would have known that the blood test to check for electrolytes should have been her top priority, and that she should have administered Lasix subsequently. This should have prevented the administration of the second dose of Lasix and the incident patient experienced.  

Recommendations

There are several recommendations that the healthcare staff should follow to prevent a similar incident. The U.S. Food and Drug Administration (FDA) recommends the use of barcodes on some drugs to prevent medication errors. Healthcare staff can use barcode scanning equipment to verify that the medicine is given to the right patient, in the right route of administration, and at the right time (FDA, 2019). Medication errors could be prevented if the healthcare staff use a barcode scanning system or something similar in healthcare settings. Doctors can checked and verified at what time the medicine was administered. Another recommendation from the Joint Commission is to use double-check labeling and correctly providing the information to the physician about the patient (PsNet, 2019). This way of communication can help with proper administration of the right medicine at the right time for next provider to check on the patient’s file. Improving communication among healthcare professionals and improved record keeping is the greatest evidence-based patient safety improvement technique that should be undertaken to avoid medical mistakes like this from occurring again. More education and training for healthcare practitioners, better communication between providers, and more thorough record keeping are all ways to achieve this goal. It is imperative that healthcare businesses invest in their employees’ communication abilities by providing them with additional training and education. Healthcare professionals also need to be taught how to give clear instructions to other medical staff and how to double-check those instructions for correctness. As a result, they may be certain that there will be no misunderstandings or missteps from one service provider to the next. The need of correctly and precisely recording all orders, instructions, and patient information is another topic that should be covered in training.

In addition, healthcare providers should adopt a consistent method for capturing and reporting patient data. Included in this should be a system for electronically recording and storing patient information as well as a standardized form that all healthcare practitioners must follow when documenting patient information. This will aid in making sure all pertinent data is recorded and preserved in a readily accessible way. To further ensure that all healthcare providers have equal access to patient information, healthcare organizations should mandate that all healthcare providers utilize the same system for capturing and storing patient information. Healthcare institutions should educate and train their personnel on proper patient care documentation practices to guarantee accurate record keeping. Included in this should be guidance on how to take accurate notes on a patient’s medical history, medicines, and test findings. This will assist guarantee that all pertinent information is recorded correctly, which is a key step in reducing the likelihood of medical mistakes. All patients’ records should be maintained up to date and correct by healthcare providers. This may be achieved by frequently reviewing and updating patient records, and by giving regular training and teaching on the need of accurate and full documentation.

Communicating with patients and their loved ones is an important part of the healthcare profession and hence training in these areas is essential. The recommendation would be strengthened by include input from patients and their loved ones. The Joint Commission also recommends the involvement of the family and the patient in the entire process of their own care (PsNet, 2019). If patients and their families feel involved in the process, they can provide clinicians with valuable information about their illness, such as symptoms, duration, onset, any reaction to the medicine, among other conditions that will increase the likelihood of a correct diagnosis and a proper treatment. Patients are important participants in their own treatment and a source of useful information about their medical history and present state, and as such they should be included in all relevant communications and record-keeping. In order to maintain the highest quality of care for their patients, healthcare professionals need also be educated on how to interact successfully with them and their loved ones. Patients and their loved ones should also be taught the value of honesty and transparency in healthcare communication. This will guarantee that doctors have all they need to give the highest quality treatment possible without risk to patients.

 

 

SCIENCE
HEALTH SCIENCE
NURSING
IHP 315