The Institute of Medicine (IOM) published, To Err is Human: Building a safer healthcare system in 1999. Errors continue to occur frequently within our healthcare system. In this paper, you will describe a critical incident. This can be an actual error, a near-miss event/potential error, or an event that caused harm to a patient. Search the internet for patient stories related to this topic. Use what happened in that patient story to guide you through the rest of the paper. For example, you could find a story on a patient that had the wrong medication given to them. There could be a variety of reasons why that event occurred, such as the label was wrong, the medication was not scanned, it was ordered incorrectly, etc. Based on that event, find related scholarly articles and answer the following questions:
1- Describe the event from the patient’s perspective
2- Define and categorize the harm that occurred based on Adverse Events, Near Misses, and Errors
3- How would you investigate this patient error /near miss /adverse event? (Discuss 3-5 tactics)
4- What data would you review within the location of where the event occurred? Include national statistics on patient harm (CDC/AHRQ, Etc.). Include graphs if available.
5- What ethical or legal considerations should be reviewed?
6- How could this be prevented from happening to other patients?
7- What role does nursing informatics play in this incident or patient safety in general?
ASSIGNMENT:
The paper should be 6 pages (including cover page and reference page). Please use at least two scholarly references (other than the website you are getting your case study from) to back up your claims. Format this paper in paragraph form using proper grammar, punctuation, and APA formatting. There is no need for an abstract

ANSWER

Healthcare Practice Errors and Possible Solution

Introduction

Patient harm is a leading causal factor of mortality in our healthcare settings and globally. Errors in medical and healthcare systems occur frequently ranging from the medications provided, miscommunication, to miss-diagnosis, technical, medical errors, delayed treatments, and lack of taking precaution, to mention a few. Patient harm involves the impairment, distress, destruction or pain resulting from mistakes in the administered healthcare treatment regimens, practices and procedures taken rather than the underlying conditions or diseases in a patient. Medical and patient harm result in health burdens, which, according to Panagioti et al. (2019), is compared to chronic diseases experience and burden (Panagioti, et al., 2019). It is crucial that the early detection of potential patient harm is conducted and effective mitigation and prevention strategies adopted. In this assignment, a case scenario of a nursing error is summarized and analyzed, identifying possible ways lack of adequate training and other nursing errors led to the death of a young boy and son. More importantly, an ethical and legal analysis is provided identifying possible review and change of some practices in the healthcare system. Finally, a significance evaluation section is provided showing the contributions of this case study to the nursing practice and improved patient safety.

Case Scenario Summary

A mother complains that Tyler, her son, did not die from “natural causes” or “SADS,” (Sudden adult death syndrome) as the coroner declared but due to nursing errors. She decided to tell the story of her son with a request that nurses and health practitioners been adequately trained and prepared for all conditions, healthcare systems to adopt better monitoring, and surveillance strategies of patients to improve patient safety. Tyler was suffering from pneumothorax, a condition involving a collapsing lung whereby it occurs when air leaks into the space between the lungs and the chest wall. The second time this incident occurred, Tyler received a pleurodesis medical procedure that would perpetually obliterate the pleural space attaching the lung to the chest walls, thus averting a relapse of a collapsing lung. However, after a successful surgery and procedure, the doctor warned of a reappearance, which required Tyler to become an inpatient. As an inpatient, he would receive increased care to control and manage post operation the pain. Hence, he was laid in a PCA (Patient-Controlled Analgesia) pump (Ireland, 2018). The pump would deliver opioids prescribed by the doctor, which would help relieve the pain. Tyler was prescribed by his doctor morphine a narcotic pain reliever. However, the next morning despite doing great the previous day, he was found unresponsive after suffering two cardiac arrests.

According to Tyler’s mother, nurses failed to adequately and correctly monitor and care for her son, as the attending nurse had not completed her training on caring for patients using PCA. Moreover, upon investigations, it was discovered by the hospital that the nurse did not check up on Tyler twice as required after 9 PM. Hence did not realize that he was using his phone at midnight, which was confirmed, he was snoring loudly, which could have signaled an obstructive sleep apnea, and that this discomfort, disorientation, and confusion in Tyler was a sign of opioid-induced respiratory depression. These nursing errors according to Tyler’s mother thus caused the death of her son and not the “natural causes” and “SADS,” described by the coroner (Ireland, 2018).

Case Analysis  

Tyler’s case study presents a severe adverse event. Adverse events in healthcare systems and nursing practice are those medically related actions taken or not taken that result in unintentional harm to a patient that could have been prevented or not. Adverse events also result in loss of and damage to patients.  In this case, the nursing errors were not a mistake; instead, they were actions not taken to provide adequate and correct care to Tyler. Tyler’s case study provides a severe adverse event, and as Haukland et al. (2019) argue, 0.3% of inpatients or hospital admittance have adverse events contributing to increasing inpatient deaths. Moreover, patients that die while admitted in hospitals experience adverse events twice the rate of the general or outpatient (Haukland, Mevik, Plessen, Nieder, & Vonen, 2019). Haukland et al. (2019) further find that among the deaths, 27.9% of the severe adverse events resulting to death, originate from poor primary care providence and 95% stem from common respiratory infections and problems (Haukland, Mevik, Plessen, Nieder, & Vonen, 2019). When critically analyzing Tyler’s case, the fact that the nurse did not check up on him twice after 9 pm as mandated and required of the hospital policies, asserts the 27.9% argument. Moreover, Tyler suffered opioid-induced respiratory depression, an assertion of the 95% claim, as it presents a respiratory problem. According to the Joint Commission, it is recommendable to take ‘extra’ caution and precaution when administering opioids to a patient for their first time. This is applicable in Tyler’s case, which was not considered as the morphine dosage, was increased according to his mother, and even though it was necessary to increase, an extra precaution in reference to the Joint Commission’s recommendation should have been applied.

Investigating the occurrences and review of nursing errors involved in this case would include conducting a systems analysis approach. Systems analysis approach consists in identifying potential sources of Tyler’s vulnerability and that of the assigned nurse establishing the accountability, shifts taken that day, and any shift burdens that may have contributed to not following hospital policies. Secondly, using the RCA (Root Cause Analysis) methods, which would involve understanding human (nurse) performance and predicting error-prone situations in the event. Some of these RCA methods include the six sigma DMAIC approach (define-measure, analyze, improve, and control), and the reliability-verification-and analysis approach (Sanchez, Lobdell, Moffatt-Bruce, & Fann, 2017).

Ethical and Legal Considerations

Managing adverse events in healthcare settings despite the continued emphasis, guidelines, and safety protocols adopted in healthcare settings, has become challenging with primary and secondary care among patients being lowered due to barriers, system, regulations, and standards complexities. Ethical considerations include the right or wrong conduct and practices. In the nursing practice, the ANA Codes of Ethics for nursing involve a set of morals and rules defining nurses’ relationships with patients, other health practitioners, and the profession itself. The provision presents four ethical principles, including autonomy, beneficence, justice, and non-maleficence. The latter is the most important in Tyler’s case, as the principle is “Do No Harm,” which maximizes the patient’s safety, including treatment regimens integrated (ANA, 2015). In this case, the hospital training, preparedness among nurses, and practices integrated in ensuring patent safety must be reconsidered. Having a nurse that was not well trained on the incident to handle the problem was a ‘wrong’ decision, the fact that the assigned nurse did not adhere to set policies of twice-patient checkups after 9 pm shows a failing organizational culture. The non-maleficence ethical principle of nursing was violated in Tyler’s case.

Legal considerations in healthcare include legal framework implications of nursing practices, including the licensure, laws applicable, and scope of practice among nurses. Legal issues in a healthcare setting include professional negligence, malpractice, harm, and failing to exercise the four ethical principles, nine provisions of the ANA, and legal frameworks (ANA, 2015). In Tyler’s case study, federal law can consider professional negligence of laws and policies including lack of conducting two checkups for the patient after 9 pm by Tyler’s nurse and negligence of the hospital to lack monitoring tools as potential legal issues and implications. Besides, health practitioners understand that patients receiving opioids are vulnerable when asleep thus requires protective wake mechanisms to support their airway. However, without the supportive tools needed among hospitals, it becomes a possible negligence situation. Moreover, having a situation where assigned nurses are untrained, it maximizes susceptibility risks of errors, mistakes, near misses, and in this case, an adverse event that would result in the death of a patient.

Significance of the Case to Improved Patient Safety

Tyler’s case presents an adverse event that resulted in a patient’s death that could have been prevented. Besides, adverse events can be prevented. In Tyler’s case, preventive aspects are presented clearly. One, the hospital policies stated that after 9 pm, patients needed two checkups, monitoring their response. Second, the signs and symptoms of opioid-induced respiratory depression Tyler exhibited, including discomfort, disorientation, and confusion, with adequate monitoring would have signaled the presence of obstructive sleep apnea that could have been corrected or addressed (Ireland, 2018). Third, health practitioners understand that patients receiving opioids are vulnerable when asleep thus requires protective wake mechanisms to support their airway. With adequate and full training, the nurse would have identified this before administering an added dosage of opioids to Tyler. Finally, the sufficient care and continuous monitoring through required checkups and electronic monitoring devices such as pulse oximetry monitors and capnography monitors would have cautioned and alerted Tyler’s assigned nurse and other health practitioners of his deteriorating respiratory status. Therefore, through these indicators, adequate, conclusive, and comprehensive continuous learning, education, experience, training of nurses and health practitioners is critical for the continued safety of patients during anesthesia. Secondly, it can be prevented by using electronic monitoring devices for continuous virtual and physician monitoring.

Nursing informatics is critical as it plays a role in delivering high-quality nursing care among patients. It integrates IT, nursing science, communication data, and knowledge in practice. In this case study through the need to integrate information systems, electronic devices, and nursing science, problem identification and preventive strategies can be identified hence maximizing continuous patient safety, key in nursing practice. This particular case study improves and contributes to clinical knowledge in caring of diverse patient populations in two way. Primarily, it enlightens on safety utilization of opioids among starter patients in anesthesia, showing that extra caution is necessary and mandatory. Even though added dosages may be necessary, drug reactions such as respiratory, opioid-induced ventilator impairments, including opioid-induced respiratory depression should be taken into consideration (Frederickson & Lambrecht, 2018). Secondly, the case study contributes to future research on efforts of improving the execution of effective practices and improvements on patient quality and safety. The case study provides a platform to bridge a gap existing between knowledge, and what theoretical foundation of nursing practices really works, the most effective practices.

In conclusion, as a nurse, enhancing the EMR and improving patient quality and safety in healthcare facilities is a professional and personal fortitude that incorporates ethical and legal standards. Continuous learning, experience, and training on various issues prone to high patient harm, including all types of errors is a step to be made as personal development, career growth, and norm of life. Moreover, disseminating adequate and correct information regarding quality care and patient safety is a critical step in the nursing profession, ensuring all nurses and health practitioners adopt and integrate these aspects as part of their daily tasks and professional trajectories.

References

ANA. (2015). Code of Ethics for Nurses with interpretative statements. Silver Spring: American Nurses Association.

Frederickson, T. W., & Lambrecht, J. (2018). Using the 2018 Guidelines from the Joint Commission to Kickstart Your Hospital’s Program to Reduce Opioid-Induced Ventilatory Impairment. THE OFFICIAL JOURNAL OF THE ANESTHESIA PATIENT SAFETY FOUNDATION, Vol 33(1), pp; 1-32. https://www.apsf.org/wp-content/uploads/newsletters/2018/june/pdf/APSF201806.pdf.

Haukland, E. C., Mevik, K., Plessen, C. v., Nieder, C., & Vonen, B. (2019). Contribution of adverse events to death of hospitalised patients. BMJ Open Quality, 8(1): e000377. doi: 10.1136/bmjoq-2018-000377.

Ireland, V. (2018, August 20). Nursing Errors Led to My Son’s Unexpected Death. Retrieved from The Doctor Weighs In: https://thedoctorweighsin.com/nursing-errors-led-to-unexpected-death/

Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., . . . Ashcrof, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, 1-10. 366:l4185 | doi: 10.1136/bmj.l4185.

Sanchez, J. A., Lobdell, K. W., Moffatt-Bruce, S. D., & Fann, J. I. (2017). Investigating the Causes of Adverse Events. OUTCOMES ANALYSIS, QUALITY IMPROVEMENT, AND PATIENT SAFETY, Vol 103(6), pp; 1693-1699. DOI:https://doi.org/10.1016/j.athoracsur.2017.04.001.