Quality And Safety Gap Analysis

Quality And Safety Gap Analysis 1quality And Safety Gap

Quality and Safety Gap Analysis Kathryn Forsyth Capella University Healthcare Quality Safety Management Quality and Safety Gap Analysis July, 2020 Proprietary This study source was downloaded by from CourseHero.com on :27:09 GMT -06:00

QUALITY AND SAFETY GAP ANALYSIS 2 Quality and Safety Gap Analysis Medication errors continues to be one of the most important areas to address in the healthcare setting. These near miss or adverse events increase patient harm, reduce quality of care, and increase healthcare costs. More common than adverse events are near misses by about 70%. Among the most common causes of death are preventable near misses and adverse events in the United States (Nambiar, Das, & Chakravarty, 2016).

This paper will review interventions to decrease near misses and adverse events which will hopefully lead to solutions. The process of administering medication is complex and involves multiple interactions and high-risk activities. Errors can happen at any stage of the process, one third of errors that are harmful to patients occur during the administration phase. Nurses administer most medications therefore any errors that occur is the nurse’s responsibility. Nurses provide a safety against medication errors by intercepting prescriber and pharmacists errors however they potentially place the patient at risk as well (Cloete, 2015).

Adverse events (ADE) is related to overuse of medication, under use of medication, or using the wrong medication. Adverse events are increasing yearly and is one of the main causes of death for hospitalized people. Nurse turnover rates and increase nurse to patient ratio have limited the quality of care provided by nurses. There are many responsibilities placed on nurses, to include providing quality of care, being cost efficient, monitoring patients, checking all orders, and verifying medications are correct. With high patient caseloads, the nurse is often tired and that is when errors are made.

One of the highest adverse events on a unit is medication errors, which is about 50% of all mistakes reported (Nambier, 2016). On the 50 bed burn unit in the past six months there has been an increase in administering the wrong drug by 40% as well as an increase in administering the drug with the right time by %, the wrong route by 16%. These errors can be attributed to distractions, lack of drug knowledge, and the physician not including enough information when writing the prescription. This is trending upwards and this plan is to address the need to implement interventions to address the issues.

This unit has also had an influx of new graduate nurses which could be another reason for the increase in errors. “Out of 168 participants, 55% admitted to making a medication error. They reported the errors had resulted from lack of experience, lack of time, unclear on the technology use, lack of adequate staffing, and needs of patients. Twenty-four percent of the respondents did not report their errors due†(Treiber & Jones, 2018, page 277). Plan Due to rising medication errors, many facilities have added systems such as High Reliability and encouraging self reporting without fear of adverse events.

The application of high-reliability principles in healthcare is being used for strategic planning. “The Joint Commission established the Center for Transforming Healthcare to work on transforming healthcare into a high-reliability industry. The Center and healthcare organizations work together to analyze breakdown in care, determine underlying causes, and use the finding to educate organizations. This effort shares data on near misses, adverse events to support learning, prevention, and improvement†(Cochrane et al, 2017, page 63). High reliability introduces methods to reduce ADE’s by addressing the need for electronic checks, use of second person to verify information, and encouraging questions.

Use of the interventions in medication administration can reduce and prevent errors. This increases safety, quality, and cost effectiveness (Hughes, 2008). High Reliability was introduced in 2013 which has led to an increase in quality of care and health initiatives (Chassin & Loeb, 2013). Proprietary This study source was downloaded by from CourseHero.com on :27:09 GMT -06:00 QUALITY AND SAFETY GAP ANALYSIS 4 New skills and ideas learned have been turned into sustainable improvements which has made measurable change in medication administration (Chassin, 2013). Most healthcare facilities are using technology to improve communication.

Written orders are often hard to read and lead to greater room for error. The electronic health records provide legible orders, is verified by the doctor, pharmacist, and nurse. The admitting nurse also review all medications with the patient to verify everything is correct. This ensures any missed information is addressed, verified allergies, and decrease errors. This practice is based on high reliability use of triple check system to improve safer health care (Chasen, 2013).

Focus for healthcare facilities should be on quality and safety of patients. Interventions should focus on areas to reduce patient harm and increase safety (Hughes, 2008). High Reliability not only focus’ on reducing medication errors but it addresses improving leadership, culture of safety, and encouragement of continuous learning (Chasen, 2013). The first step of the process is to start the triple check system, this will allow the nurse to use technology with a fellow nurse to review the information and verify it is correct which will assist with catching errors. Improving nurse education of pharmacology is needed for a better understanding of medication.

This will help the nurse know when to question an order and improve patient safety. Around six percent of nurse do not have proper knowledge and understanding of medications (Aronson, 2013). Safer medication initiatives provider better outcomes for patients. Quality improvement projects are dependent on ability to measure goals and self-reporting. By analyzing the data, using statistics we can identify gaps in areas to be able to address the issues.

The use of technology has been able to better track interventions, goals, and outcomes. By using technology, we are enabling the nurse to better care for the patient, verify information, research information at bedside, and improve patient satisfaction. The focus is on interventions that improve nurse knowledge, use of time, increase safety, and reduce near miss and adverse events. Some barriers to the plan would include communication and a resistance to change by the staff. Communicating with an interdisciplinary team, between staff, and with patients can be difficult at times as there is a way a person speaks which may not what the person understands.

We must remember to consider the ability of each person to understand what is being said, nonmedical people will not understand medical language. To address this issue and improve communication, the facility can use the SBAR tool. SBAR stands for situation, background, assessment, recommendations (O'Shea & Roney, 2020). Use of the SBAR can provide the staff with a method to provide a clear, concise report which leads to better patient care. Providing standard reporting tool, the nurse can provide effective communication, allows the other party to ask questions, and have a better understanding of what is needed to be done during their shift.

This will also improve communication between nurse and patient/family. The need to remain up to date on current evidence-based practices to improve quality, safety, patient outcomes, and improve medication safety (Hughes, 2008). Administration needs to encourage open, honest communication without fear of retribution to improve relationship and trust between staff. This will improve self-reporting of near misses and adverse events that can become teaching opportunities later. Evidence based leadership (EBL) was created in response into organizational change to research that identified alignment and accountability.

EBL aligns all functions to prioritize goals aligned with the mission, vision, and values of the organization. EBL is adaptable, comprehensive, flexible, and scalable. EBL incorporates aligned goals, behaviors, and processes, each with a set of tools and techniques. EBL is an integral process for culture transformation and performance improvement, various goals and initiatives can be layered into the framework to support the goals (Cochrane, 2017). The organization administration and leadership are supportive of the need for new policies and procedures related to medication administration.

The need to decrease adverse events and near misses on the burn unit is needed immediately. The first steps to implement a double check system as well as increasing education on medications have been widely accepted by all stakeholders. The leaders have agreed there is a need for improved communication and will have a multidisciplinary team come up with a standard reporting tool that incorporates SBAR. Conclusion Change is always challenging, however providing proper education, tools, resources, and realistic interventions and goals can improve the willingness of staff to accept change. Medication errors will likely always be an issue as there is a human component to medication administration and humans make mistakes.

We can implement ways to reduce errors, recognize gaps, and improve communication to decrease errors, improve patient safety, and patient outcomes. The healthcare system can implement safer interventions with the use of technology, SBAR for handoffs, education, communication, and evidence-based leadership to help reduce errors, improve communication, and potentially save lives.

References

• Aronson, J. K. (2013). Medication errors: Definitions and classification. British Journal of Clinical Pharmacology, 67(6), 671–674. https://doi.org/10.1111/j.1365-2125.2009.03415.x
• Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: getting there from here. The Milbank Quarterly, 91(3), 459–490. https://doi.org/10.1111/1468-0009.12023
• Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1), 29–32. https://doi.org/10.7748/cnp.14.1.29.e1148
• Cochrane, B. S., Hagins, M., Picciano, G., King, J. A., Marshall, D. A., Nelson, B., & Deao, C. (2017). High reliability in healthcare: Creating the culture and mindset for patient safety. Sage Publications. https://doi.org/10.1177/1741143217699580
• Hughes, R. G. (2008). Tools and strategies for quality improvement and patient safety. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 951–979). Agency for Healthcare Research and Quality.
• Nambiar, B. C., Das, A. K., & Chakravarty, A. (2016). Medication error: An unfortunate reality. Medical Journal Armed Forces India, 72(3), 234–239. https://doi.org/10.1016/j.mjafi.2015.04.011
• O'Shea, E. R., & Roney, L. N. (2020). SBAR: Situation, Background, Assessment, Recommendation. Nurse Educator, 45(2), 104–108. https://doi.org/10.1097/NNE.0000000000000759
• Treiber, L., & Jones, J. (2018). After the medication error: Recent nursing graduates' reflections on adequacy of education. Journal of Nursing Education, 57(5), 277–280. https://doi.org/10.3928/01484834-20180403-02