Construct A Case Report: 1750-2000 Words On A Prob

Construct A Case Report 1750 2000 Words That Includes A Problem Or

Construct a case report that includes a problem or situation consistent with a DNP area of practice. Review the AHRQ and the IOM report ("To Err Is Human" and "Crossing the Quality Chasm") to develop the case report. Apply quality and/or safety concepts to describe the understanding of the problem or situation of focus. Apply one or more quality and/or safety concepts to the recommended intervention or solution being proposed. Develop the case report across the entire scenario from the identification of the clinical or health care problem through the proposal for an intervention, implementation, and evaluation using an appropriate research instrument. Describe the evaluation of the selected research instrument in the case report. Lastly, explain in full the tenets, rationale for selection (empirical evidence), and clear application using the language of quality and/or safety within the case report.

Paper For Above instruction

Introduction

The escalating rates of hospital readmissions and medication errors pose significant challenges within healthcare, directly impacting patient safety and care quality. A prevalent issue in many clinical settings is adverse drug events (ADEs) resulting from communication failures and inadequate safety protocols. This case report explores a scenario within a primary care setting where these issues lead to a preventable hospitalization. Grounded in the frameworks established by the Agency for Healthcare Research and Quality (AHRQ) and the Institute of Medicine (IOM) reports, "To Err Is Human" and "Crossing the Quality Chasm," the report emphasizes the importance of implementing safety and quality improvement strategies derived from empirical evidence and best practices. The overarching goal is to identify, analyze, and propose a comprehensive intervention to reduce ADEs, enhance communication, and foster a culture of safety.

Literature Review

The literature underscores the critical role of communication and system-based approaches in reducing healthcare errors. Carayon et al. (2014) highlight that errors often stem from systemic issues such as poor communication, workflow inefficiencies, and lacked standardization, aligning with the principles articulated in "Crossing the Chasm." The IOM's recommendation to create a culture of safety involves promoting transparency, non-punitive reporting, and continuous learning (Kohn, Corrigan, & Donaldson, 1999). AHRQ's efforts focus on evidence-based tools like medication reconciliation and electronic prescribing, which have demonstrated reductions in ADEs (Gandhi et al., 2005).

The integration of health information technology, particularly electronic health records (EHRs), has shown promise in improving medication safety. For example, Bates et al. (2003) documented a significant decrease in medication errors following EHR implementation. Conversely, challenges with alert fatigue and system workarounds highlight the need for careful intervention design (Ancker et al., 2017). Literature also supports the utility of standardized communication protocols such as SBAR (Situation, Background, Assessment, Recommendation) to improve interdisciplinary communication and reduce errors (Haig, Sutton, & Whittington, 2006).

Emerging evidence suggests that multifaceted interventions—combining technological, educational, and organizational strategies—are most effective in fostering safety and reducing ADEs (Chandler et al., 2016). Despite these advances, gaps remain in consistent implementation and evaluation, underscoring the need for tailored solutions validated through empirical research.

Case Description and Theoretical Perspective

The selected case involves a 65-year-old patient with multiple chronic conditions, including hypertension, diabetes, and osteoporosis. The patient experienced an ADE—specifically, a hypoglycemic episode—due to a medication error involving insulin management. The error occurred because of miscommunication during a transition from hospital to outpatient care, compounded by incomplete medication reconciliation and suboptimal education regarding insulin titration.

From a systems theory perspective, the error exemplifies breakdowns at various points in the care continuum, emphasizing that healthcare errors are often the result of complex interactions within system components, not solely individual negligence (Senge, 1990). Applying this framework, the focus is on modifying systemic factors—such as communication pathways, safety protocols, and information technology—to prevent similar occurrences.

Discussion: Synthesized Literature Findings

The synthesis of literature indicates that addressing factors like communication failures, inadequate medication reconciliation, and insufficient safety culture is essential for error reduction. Interventions that incorporate technology—such as interoperable EHRs with clinical decision support—have demonstrated efficacy. However, without fostering a safety culture that encourages reporting and continuous improvement, technological tools alone are insufficient (Kohn et al., 1990).

Effective strategies must also include staff education and engagement. Singh et al. (2017) emphasize that empowering frontline providers with safety tools and creating an environment open to reporting errors fosters proactive error prevention. Standardized communication tools like SBAR improve clarity during handoffs, which is critical during transitions of care (Handoff Communication Consortium, 2010). Moreover, regular audits and data-driven feedback facilitate ongoing safety improvements.

The literature also advocates for adopting a systems approach combined with human factors engineering principles, emphasizing designing safety into processes rather than relying solely on individual vigilance (Reason, 2000). The success of these strategies depends on leadership commitment, resource allocation, and integration into organizational policies.

Summary of the Case

In summary, the case highlights a preventable ADE caused by communication failures and systemic errors during a care transition. The error underscores vulnerabilities in medication management and information transfer, emphasizing the need for comprehensive safety strategies aligned with systemic theories and evidence-based practices.

Proposed Solutions

To address these gaps, a multifaceted intervention is proposed. First, implementing an integrated electronic medication reconciliation process at every transition point can significantly reduce errors. This involves standardizing documentation, leveraging clinical decision support alerts, and engaging patients in medication management through education.

Second, adopting a structured handoff protocol, such as SBAR, ensures clear, concise communication among multidisciplinary team members. Training staff on these protocols fosters a safety culture emphasizing accountability and transparency.

Third, establishing a continuous quality improvement (CQI) program that uses data analytics to monitor ADE rates and communication effectiveness will facilitate ongoing assessment and intervention refinement. Encouraging frontline staff to participate in safety discussions and error reporting fosters ownership and accountability.

Implementing these solutions requires an organizational commitment supported by leadership, policies, and resources to ensure sustainability.

Data Collection Instrument and Evaluation

To evaluate the effectiveness of the proposed interventions, the Safety Attitudes Questionnaire (SAQ) will be utilized. The SAQ measures safety climate across domains such as teamwork, communication, and perceptions of safety. It is a validated tool with demonstrated reliability in diverse healthcare settings (Sexton et al., 2006).

The SAQ can be administered pre-intervention and periodically post-intervention to assess changes in safety climate perceptions. Additionally, quantitative data on ADE incidents and medication reconciliation compliance rates will be collected through electronic health records. The combination of subjective survey data and objective clinical outcomes provides a comprehensive evaluation of intervention impact.

The instrument’s evaluation involves analyzing changes over time using statistical methods such as paired t-tests and control charts to determine significance and trends. Correlating safety culture improvements with reductions in ADEs offers empirical evidence of intervention effectiveness, aligning with quality improvement principles.

Conclusion

This case underscores the complexity of healthcare errors rooted in systemic issues—particularly communication and safety protocols. Applying a systems-based perspective, supported by literature and empirical evidence, informs the development of targeted interventions aimed at reducing ADEs. Implementing integrated medication reconciliation, standardized handoff communication, and fostering a safety culture are critical steps toward enhancing patient safety. Continuous evaluation using validated instruments like the SAQ ensures that improvements are sustained, aligning with the overarching goals of quality and safety in healthcare. The integration of evidence-based strategies, organizational commitment, and robust evaluation frameworks will effectively address system vulnerabilities, ultimately advancing the quality of patient care.

References

• Bates, D. W., et al. (2003). Ten commandments for effective clinical decision support: Making the right thing to do the easy thing to do. Journal of the American Medical Informatics Association, 10(4), 387–393.
• Chandler, G. H., et al. (2016). Multifaceted interventions to improve medication safety: A systematic review. BMJ Quality & Safety, 25(4), 318-330.
• Gandhi, T. K., et al. (2005). Potential adverse drug events and errors in care delivered to hospitalized adults. JAMA, 293(21), 2834–2841.
• Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal of Hospital Medicine, 1(3), 147–151.
• Handoff Communication Consortium. (2010). Standardized provider hand-off strategies and tools: A systematic review. Agency for Healthcare Research and Quality.
• Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (1999). To Err is Human: Building a safer health system. National Academies Press.
• Senge, P. (1990). The fifth discipline: The art & practice of the learning organization. Doubleday/Currency.
• Sexton, J. B., et al. (2006). The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research, 6, 44.
• Singh, I., et al. (2017). Building a safety culture: A systematic review of intervention strategies. BMJ Open Quality, 6(2), e000254.
• Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770.