MSN-FP6016 Assessment 1 Adverse Event Or Near Miss Analysis

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Example 1

Analysis of a Near Miss or Adverse Nursing Event

Adverse events lead to fatal patient outcomes, while near misses are opportunities to improve healthcare delivery processes and prevent adverse events from occurring. Adverse events are a leading cause of death among emergency department patients. They cause premature death and preventable patient morbidity. Adverse events should be followed by quality improvement interventions to prevent the recurrence of these events in the future. This essay focuses on developing quality improvement interventions to prevent the recurrence of an identified adverse event.

A 64-year-old schizophrenic male in the psychiatric ward started complaining of severe shortness of breath, severe weakness, nausea, vomiting, and severe cramping, which began a day ago with increasing severity. The doctor diagnosed him with hypokalemia (2.8mmol) and noted he was on long-term management of schizophrenia with Risperidone and Quetiapine. The doctor prescribed a 200mEq potassium infusion for six hours (a flow rate of 33mEq/h).

The nurse in the psychiatric ward, a newly employed nurse in her first week in the ward, panicked at seeing the condition of the man. She quickly infused the patient with the prescription, left it running, and attended to other patients. After an hour, the nurse came back to find the patient still and cold. Postmortem results revealed that the patient died from fatal arrhythmias, and a lethal dose of potassium was found in the blood.

ASSESSMENT_1_Adverse_Event_or_Near-Miss_Analysis_Scoring_(_RUBRIC)

Assignment1_Adverse_Event_or_Near-Miss_Analysis_Instructions

Analysis of Missed Steps and Protocol Deviations Related to the Adverse Event

Some major causes of errors include panic, insufficient knowledge, confusion, and professional negligence (Senders, 2018). In clinical settings, errors may be chronic or acute, and a single error leads to a series of errors that lead to morbidity or mortality. A root cause analysis identified several missed steps.

Risperidone and quetiapine are antipsychotic medications administered to schizophrenic patients. These drugs are prone to causing hypokalemia, and thus, patients are monitored for hypokalemia (Yang, Guo, & Lee, 2018). The patient’s potassium levels were not monitored, dropping far below the normal range. Normally, if these drugs lead to hypokalemia, they are changed to her therapies such as amisulpride.

Another error was that the nurse administered the drug bypassing the IV infusion pump, hence major errors in flow rate. The nurse panicked after realizing the errors committed, which led to further errors. In addition, the nurse did not monitor the drug flow rate and did not pay attention to the prescription.

Potassium is a slow IV, and administering it as a bolus or fast has lethal effects, as it occurred in this case (Du, Mou, & Liu, 2019). The patient under Potassium infusion was not monitored on the ECG as stipulated by the organizational policies. He was left unmonitored, violating the organizational protocols. If these policies were implemented, the adverse event would have been effectively prevented from the various opportunities in the event.

Effects of the Adverse Event on the Various Stakeholder

Adverse effects have various effects on the various stakeholders. These are the patients and their families, healthcare providers, and the organization. The organization is tasked with educating staff on the management of various medications. The organization is also responsible for increasing the vigilance of its staff through proper training. The organization suffers from such adverse events greatly. The organization’s reputation is always at stake.

Adverse events soil an institution’s reputation. A bad reputation drives clients away in fear of similar events from occurring to them. Clients may also give a poor patient satisfaction rate, significantly affecting an organization’s accreditation. These poor results also reduce the remuneration by insurance such as Medicaid, whose payment is based on the perceived quality of services. In addition, the institution may incur high lawsuit costs from legal proceedings if the patient’s family decides to sue the organization.

The interprofessional team maintains patient safety through collective decision-making and quick and informed consultation. The team is responsible for reviewing care and ensuring all patients receive the right care, which did not happen. The interprofessional team is also exposed to several effects, such as retrenching members or the whole team following a disciplinary hearing. Most often, the institutions dismiss interprofessional team members found guilty. In some instances, healthcare providers have been charged with murder and found guilty, and they spend time in jail or pay hefty fines.

Healthcare providers who are jailed suffer from ruined careers and have difficulties nursing their careers even after completing the jail terms (Tigard, 2020). In addition, the organization may also punish these healthcare professionals as per the stipulation of the organizational policies, such as suspension or paying for the damages in cases of incurred healthcare costs. The staff may also be overcrowded by the guilt of having killed or maimed an individual, negatively affecting their career life (productivity and job satisfaction) (Tigard, 2020).

The patient is the most affected stakeholder in adverse events. Patients should participate in their care by following instructions, asking questions, and seeking clarity before taking drugs and other interventions. However, in most adverse events like this, patients cannot prevent such events beyond their roles.

The patients suffer from high healthcare costs from healing preventable errors (Carver et al., 2021). In some instances, such as this case, patients die and cause grief to their families. Experiencing near-miss events also affects an individual’s care-seeking behavior and discourages them from seeking healthcare services in the future due to fear (Carver et al., 2021). Fear may also prevent families from seeking healthcare services.

All healthcare professionals, organizations, and patients must promote patient safety and prevent these sentinel events from occurring (Godshall & Riehl, 2018). Healthcare professionals were expected to share their roles in inpatient care, and the other nurses should have also helped monitor this patient. Care collaboration improves the quality of care and immediacy and promotes patient safety.

The doctor should have followed the patient to see their progress and determine if they received the prescribed medications. This nurse was left unsupervised, and she lacked proper knowledge of handling medications and organizational policies regarding medication administration. The department leader should have adequately oriented the nurse to her roles and assigned a supervisor to ensure safe practice. These activities would have effectively prevented the adverse event from happening.

The healthcare institution developed some interventions to prevent such events from happening in the future. The institution management instructed that every medication procedure be carried out with an assistant. Using assistants reduces medical errors significantly and enhances the responsibility of healthcare providers (Gomes et al., 2021). The healthcare institution passed the regulation and included it in the organizational policy. The policy also requires that all nurses who provide care without consultation receive disciplinary action relative to the severity of their actions. The policy change has significantly improved the nurses’ vigilance, responsibility, and subsequent efficacy.

Evaluation of Quality Improvement Technologies

The major effects of adverse effects and sentinel events are increased mortality and morbidities such as paralysis, organ failure, and mental health issues. Healthcare data is integral in planning patient care. Healthcare technologies help improve healthcare efficiencies and promote patient safety. Some leading healthcare technologies are computerized provider order entry (CPOE) and the clinical decision support systems (CDSS).

CPOE helps professionals use standardized drug ordering systems, while the CDSS helps healthcare providers make informed decisions by availing the required disease of drug-specific information (Angela & Adisasmito, 2019). The CPOE and the CDSS would have helped prevent the errors, such as the missed ECG monitoring, thus preventing the event.

Healthcare quality improvement projects are based on well-prepared goals and objectives that help evaluate and ensure their success. Healthcare dashboards are healthcare technology-based programs that help institutions determine their position relative to achieving the local, state, and federal regulations set goals and objectives.

Dashboards help organizations to remain focused on maintaining high-quality care and patient safety (Kunjan et al., 2019). Dashboards and CDSS systems guide professionals in decision-making by ensuring their decisions are well-informed and are aligned with the organizational goals and objectives. Dashboards and other healthcare technologies, such as CDSS and CPOE could significantly improve healthcare efficiencies.

Relevant Metrics for the QI

Dashboards rely heavily on key performance indicators based on patient-clinician relationships. Electronic health records provide information on these processes and outcome key performance indicators. Many institutions, such as the Agency for Healthcare Research and Quality, control patient care and the Institute of Medicine (IOM) are concerned with healthcare improvement. AHRQ develops and enforces national dashboard metrics allows organizations to create their dashboards and work towards achieving the nationally set benchmarks.

Through the National Inventory of Mental Health Quality Measures, AHRQ sets national benchmarks to help healthcare professionals ensure patient safety in psychiatric wards. These include measures such as the proportion of psychiatric patients who developed severe side effects, the percentage of patients educated, the proportion of psychiatric patients admitted for specialized care, and the mean duration between seeking and receiving healthcare services (AHRQ, n.d.). The metrics specific to medication errors include the type, cause (process, underlying condition, patient, or care provider), and severity (mild to severe) (AHRQ, 2021).

Examples of metrics relevant to this institution would include a) the mortality rates from uncomplicated diseases, b) medication errors death and mortality rates, c) the percentage follow-ups accomplished, and d) medication errors near-miss reports (AHRQ,n.d.). As mentioned earlier, healthcare technologies combined with well-prepared dashboard metrics will help the organization promote high-quality decisions, better healthcare efficiencies, patient safety, and thus, quality improvement.

Dashboards are important to healthcare institutions in various ways. They act as evaluation tools, motivate staff, assist in rational decision-making, provide room for personal improvement, they increase staff morale, accountability, and responsibility, thus improving healthcare efficiencies (Kunjan et al., 2019; Isazan et al., 2020; Pestana et al., 2020).

Quality Improvement for the Hospital

The IV drug pump, a bedside ISBAR patient handing-over tool, and medication companions are current evidence-based strategies that help reduce errors (Carver, Gupta & Hipskind, 2021). Medication companions help improve efficiency by accurately reading and interpreting orders with improved knowledge and decreased error chances. IV drug pumps help reduce dosage, frequency, and flow rates errors. Handing patients by the bedside makes nurses familiar with the patients’ unlike handling over at the nurses’ station.

Several quality improvement models can be applied in healthcare settings, including the Donobedian, PDSA, and the LEAN Six Sigma DMAIC models (Goldman et al., 2021). The Donobedian model focuses on the progress of the QI project. The PDSA focuses on determining problems and helps plan strategies to address the issues. However, it does not determine the causes of errors to help address them. LEAN thinking and the Six Sigma DMAIC model focus on the causes of errors and develop cause-specific strategies to address these problems (AHRQ, 2021). The model is thus the most ideal in creating the QI outline.

From the seen interventions and research, the QI interventions outline will highly benefit from the LEAN thinking and Six Sigma DMAIC model, dashboard program, and the healthcare technologies (CDSS and CPOE) to support decision making and improve healthcare efficiency. These components will help create a strong quality improvement initiative that will help prevent other adverse events from occurring in the future. In addition, these components can be utilized in all hospital departments to promote patient safety and high-quality care.

Conclusion

Healthcare institutions still suffer the burden of medication errors. They lead to various consequences, such as morbidities and, at times, death, as seen above. While medication errors seem unpredictable, they can be avoided by increased vigilance and better healthcare technologies and strategic planning. Current initiatives such as healthcare dashboards can help improve healthcare efficiencies.

In addition, other healthcare technologies, such as the CPOE and CDSS systems, can help improve healthcare delivery and promote professional practice. The Six Sigma model is ideal for developing QI initiatives in healthcare settings. Healthcare leaders should invest in investigating adverse effects and identifying strategies to prevent the recurrence of these errors in the future.

References

Agency for Healthcare Research and Quality (AHRQ) (2021). Network for Patient Safety Databases. Medication or Other Substance Dashboard. Retrieved 14^th January 2021, from https://www.ahrq.gov/npsd/data/dashboard/medication.html

Agency for Healthcare Research and Quality (n.d.). Mental Health Quality Measures. Retrieved 28^th January 2022, from http://www.cqaimh.org/pdf/measure_EPS.pdf

Angela, N., & Adisasmito, W. B. B. (2019). Computerized Physician Order Entry (CPOE) in Reducing Medication Error: A Narrative Review. Jurnal Administrasi Rumah Sakit Indonesia, 5(3). http://dx.doi.org/10.7454/arsi.v5i3.3030

Carver, N., Gupta, V., & Hipskind, J. E. (2021). Medical error. (1^st Ed.). StatPearls [Internet].

Du, Y., Mou, Y., & Liu, J. (2019). Efficiency evaluation and safety monitoring of tailored rapid potassium supplementation strategy for fatal severe hypokalemia. Experimental and Therapeutic Medicine, 17(4), 3222–3232. https://doi.org/10.3892/etm.2019.7292

Godshall, M., & Riehl, M. (2018). Preventing medication errors in the information age. Nursing2020, 48(9), 56-58. http://dx.doi.org/10.1097/01.NURSE.0000544230.51598.38

Goldman, J., Smeraglio, A., Lo, L., Kuper, A., & Wong, B. M. (2021). Theory in quality improvement and patient safety education: A scoping review. Perspectives on Medical Education, 10(6), 319–326. https://doi.org/10.1007/s40037-021-00686-5

Gomes, A. N. H., da Silva, R. S., Alves, E. B., da Silva Moura, G., & de Oliveira, H. M. (2021). Safety in the administration of injectable medications: Scoping review. Research, Society and Development, 10(6), e1510615381-e1510615381. https://doi.org/10.33448/rsd-v10i6.15381

https://www.ncbi.nlm.nih.gov/books/NBK430763/

Isazad, M. M., Ojo, A., & Sullivan, F. J. (2020, January). Investigating Analytics Dashboards’ Support for the Value-based Healthcare Delivery Model. In Proceedings of the 53rd Hawaii International Conference on System Sciences. https://doi.org/10.1145/3335082.3335109

Kunjan, K., Doebbeling, B., & Toscos, T. (2019). Dashboards to support operational decision making in health centers: a case for role-specific design. International Journal of Human-Computer Interaction, 35(9), 742-750. https://doi.org/10.1080/10447318.2018.1488418

Leape L. L., (2021). We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative. In: Making Healthcare Safer. Springer, Cham. https://doi.org/10.1007/978-3-030-71123-8_6

Pestana, M., Pereira, R., & Moro, S. (2020). Improving health care management in hospitals through a productivity dashboard. Journal of medical systems, 44(4), 1-19. https://doi.org/10.1007/s10916-020-01546-1

Tigard, D. W. (2020). Taking one for the team: a reiteration on the role of self-blame after a medical error. Journal of medical ethics, 46(5), 342-344. http://dx.doi.org/10.1136/medethics-2019-105846

Yang, Q., Guo, X., & Liu, D. (2018). Hypokalemia Caused by Quetiapine and Risperidone Treatment in Schizophrenia: A Case Report. Shanghai archives of psychiatry, 30(3), 204. https://dx.doi.org/10.11919/j.issn.1002-0829.217168

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Instructions

Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.

Introduction

Healthcare organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication.

Also Read:

Assessment 2 Quality Improvement Initiative Evaluation

MSN-FP6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

MSN-FP6016 Assessment 4 Assessment Strategies and Complete Course Plan

Overview

This assessment aims to allow you to focus on a specific event in a healthcare setting that impacts patient safety and related organizational vulnerabilities and proposes a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a healthcare professional.

Healthcare organizations strive for a culture of safety. Yet, medical errors continue to occur despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.

For clarification, the National Quality Forum (n.d.) defines the following:

Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Instructions

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis

Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:

Analyze the implications of the adverse event or near miss for all stakeholders.
Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.

- Evaluate how other institutions integrated solutions to prevent these types of events.

- Incorporate relevant metrics of the adverse event or near miss to support need for improvement.

Outline a QI initiative to prevent a future adverse event or near miss.
Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.
Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance.
APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

Competencies Measured in MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.

- Analyze the implications of an adverse event or a near miss for all stakeholders.

- Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.

- Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.

Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.

- Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.

Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

- Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Reference

National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx

Guiding Questions

Adverse Event or Near Miss Analysis

This document is designed to give you questions to consider and additional guidance to help you successfully complete the Adverse Event or Near Miss Analysis assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment. Do not turn in this document as your assessment submission.

For examples of adverse events or near misses, visit:

Agency for Healthcare Research and Quality. (2021). WebM&M cases & commentaries. https://psnet.ahrq.gov/webmm

Analyze the implications of the adverse event or near miss for all stakeholders.

What are the possible short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community, et cetera)?
What are the responsibilities and actions of the interprofessional team related to the adverse event or near miss?
What measures should have been taken? Who are the responsible parties or roles?
How did the incident impact the stakeholders? Did it change how they do their work, or how or what they report?

Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.

How did the event result from a patient’s medical management rather than from the underlying condition?
What were the missed steps or protocol deviations that led to the adverse event or near miss? What was overlooked? Why?
What kind of interprofessional communications could have prevented this event?
To what extent was the adverse event or near miss preventable?

Evaluate quality improvement actions or technologies related to the event that are required to reduce risk and increase patient safety.

What quality improvement technologies are in place to increase patient safety and reduce risks that pertain to this adverse event? What would prevent it from happening in the future?
Are those technologies being utilized appropriately? How could they be more usefully employed?
How do other institutions prevent these types of events from occurring?
What data are generated from the facility’s dashboard related to the selected incident? (By dashboard, we mean the data that are generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management. This is not something you will find online or in the Capella library.)
What data are associated with the adverse event or near miss? What do the relevant metrics show? (Patient satisfaction and readmission rates are important metrics. Look at trending data and compare to see where relevant metrics are headed.)
What research or data related to the adverse event or near miss is available outside of your institution?
Compare internal data to external data. What do you find?

Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.

How was the incident managed and monitored in the selected institution?
What quality improvement initiatives have been shown to work? Why are they successful? What is the evidence?
What elements can be applied to prevent future adverse events or near misses?

Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Is your analysis logically structured?
Is your analysis 5–7 double-spaced pages (not including title page and reference list)?
Is your writing clear and free from errors?
Does your analysis include both a title page and reference list?
Did you use a minimum of three sources? Were they published within the last five years?
Are they cited in current APA format throughout the plan?

MSN-FP6016 Assessment 1 Grading Rubric

Distinguished

Analyzes the implications of an adverse event or a near miss for all stakeholders and identifies assumptions on which the analysis is based.

Analyzes the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).

Evaluates and identifies quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety. Identifies criteria to evaluate the actions or technologies discussed.

Outlines a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.

Conveys clear purpose, in a tone and style well-suited to the intended audience. Supports assertions, arguments, and conclusions with relevant, credible, and convincing evidence. Exhibits strict and nearly flawless adherence to organizational, professional, and scholarly writing standards, including APA style and formatting.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Sample Approach

Introduction

Re-envisioning the widespread commitment and the diagnostic process is critical to illuminate the diagnostic error’s blind spots and improve healthcare diagnosis. Diagnostic errors are increasingly growing and are becoming a serious issue in the healthcare unit, and there seems to be not much that can be done to bring a change. However, despite the increasing cases of diagnostic errors, the hospitals must make a few recommendations to ensure they improve patient outcomes and address other challenges. This paper will focus on a misdiagnosis case in my workplace and describe stakeholders’ implications to provide functional recommendations to resolve the issue.

I will share my colleague’s experience with a mid-aged woman, Mrs. Johnson, who had a rectal bleeding problem. In her case, the doctor conducted a limited sigmoidoscopy test, which came out negative. The bleeding, on the other hand, did not stop even after she underwent numerous treatment methods. After about two years, the patient’s condition worsened, and she had to return to the facility. As per her assessment, she had lost at least 10 kgs within that time.

After further evaluation of her condition, the doctor diagnosed her with colon cancer, which was at a relatively advanced stage. The doctor indicated in his assessment that based on the previous medical record, the issue could have been identified earlier when there were still chances for a cure. However, the event was ruled adverse due to the medical negligence she had encountered previously.

Analysis of the Missed Steps That Lead To the Adverse Events

A bright bleeding per rectum is a common clinical issue that adults of all ages often experience. However, when it comes to young adults, the issue is not well reported, causing an assumption that it is not common for a particular age group (Segev et al., 2018). In this regard, doctors need to perform a colonoscopy within the first time of diagnosis to evaluate rectal bleeding considering that it could present multiple risks of colorectal neoplasms. According to Jodal et al. (2019), at least 10% of patients with rectal bleeding have been diagnosed with colorectal cancer. It would have also been helpful for the doctor to consider other options in his testing, such as adenomatous polyps.

Another reason this was considered an adverse event was because the doctor would have conducted further tests when the patient expressed that the bleeding was still there rather than expecting the issue to magically disappear. The doctor failed to test for neoplastic lesions, which are located in the distal colon of almost all patients with rectal bleeding. There is also a possibility of patients having hemorrhoids and adenocarcinoma in the transverse colon. The doctor should have also considered tumors as a reason for the bleeding, hence conducting a colonoscopy to rule out the issue (Jodal et al., 2019).

The distribution of polyps is very similar to that of colorectal cancer patients. Therefore, the doctor’s job was to ensure they ran a comprehensive test and considered a few possibilities. Rigid sigmoidoscopy is a diagnostic procedure used to rule out colorectal pathology (Segev et al., 2018). It is frequently performed in outpatient clinics and requires minimal intestinal preparation. On the other hand, flexible sigmoidoscopy is a more advanced test with a higher diagnostic value and less patient discomfort than a rigid sigmoidoscopy.

As for the case of Mrs. Johnson, a middle-aged patient, it would have been convenient to get her screened for colorectal cancer. The patient and the doctor should have also had an agreement on the appropriate tests between sigmoidoscopy and colonoscopy that will be effective and bring the necessary result. Data provided by Segev et al. (2018) indicate that at least 90% of the patients in the clinic are flexible to take sigmoidoscopy, which is clinically significant.

On the other hand, those who may opt for a colonoscopy are also guaranteed that the test is effective and will bring convenient results for those who need colorectal cancer screening and are above the age of 50 years (Cheluvappa & Selvendran, 2020). It would also be convenient to investigate whether any visible cultural differences between the patient and the physician could have impacted the course of treatment. The difference in cultural understanding directly influences the treatment approach for various patients.

Implications of Medical Negligence of Stakeholders

Patients have an ethical responsibility toward their health and the cost regulations. However, the regulations cannot effectively be implemented or strictly force people into living a healthy lifestyle. By embracing a healthy lifestyle, it is guaranteed that the cost of healthcare will be significantly reduced. On the other hand, it is critical for people with medical insurance to have the best insurance cover possible to make them comfortable, especially with the current expansion of innovation.

The doctors, conversely, are expected to ensure they provide the expected services to their target clients. However, it is also convenient to understand that the best medical services should not necessarily be expensive. Therefore, the doctors and the patients are expected to work together and ensure they reach a sensible health decision. As for the case of Mrs. Johnson, it would have been best for her to visit the doctor as soon as she noticed the issue had not been resolved rather than waiting all that long.

Additionally, considering that she was not satisfied with the conclusion of the previous doctor, it would have been best for her to seek a second and third opinion. The short-term consequences of the near-miss incident were low customer satisfaction, which resulted in a reduction in the number of patients served by the hospital. The problem could result in significant losses in the long run.

Customers would cease coming to the hospital, and there is a considerable risk of legal action, which would result in financial losses. The problem will be remedied by immediately treating the patient and finding measures to reimburse her for the initial misdiagnosis (Sapoelete et al., 2021). For example, the hospital could agree to pay for all of her future treatments, whether they occur at the hospital or elsewhere.

Interprofessional Team

Patients depend on interprofessional team intervention to receive reliable care and monitor the rise in healthcare costs. However, on the part of the interprofessional team, they often have limited time to attend to specific patients and review their specific medical charts due to the increasing number of patients and the high cost of healthcare. Such issues have contributed to the increased cases of medical negligence (Cheluvappa & Selvendran, 2020). Health professionals are committed to doing everything possible for the patient’s benefit. Doctors are expected to make decisions on their own, with little regard for the interests of their patients. Even while they act freely, the interprofessional team should respect patients’ rights while deciding on the best care for them.

Community

A community’s role is to guarantee that all patients receive the greatest treatment options possible. The community owes it to health practitioners to push them to offer the appropriate degree of treatment for all patients, regardless of insurance or cost, while also addressing their needs (Curtis et al., 2021). The community’s responsibility is to ensure that all patients, affluent and poor, receive equal treatment while seeking medical care.

Diagnosis and Technologies

Understanding the patient’s information in detail regarding diagnosis and treatment is critical. Therefore, the physician has to ensure they use the best and most relevant technology that will help in the diagnosing and treatment process to guarantee improved patient outcomes. With the best technology, physicians can lower the cost of treatment and reduce the time spent on specific patients (Carayon & Hoonakker, 2019). In the case of Mrs.

Johnson, there is a higher possibility that her condition was not discovered earlier due to a lack of proper inclusion of technology in the diagnosis process. In the healthcare setting, service delivery largely depends on collecting, storing, and analyzing patient information. Therefore, when it is not done effectively, the service delivery will be impaired, affecting the patient outcome. To achieve better results, using technology such as Health Information System (HIS) guarantees better clinical data collection and storage, improving patient care outcomes (Sapoelete et al., 2021).

The technology helps physicians capture specific patient information and minimize the risks of duplicating patient information, preventing misdiagnosis. HIS is also easy to use and super friendly to the users. Regarding maintenance, the technology is relatively straightforward and does not attract huge costs.

Metrics for Adverse Event Support

Cases of medical errors are increasingly growing, affecting people from across all age groups. Each year, nearly 230000 people die as victims of medical negligence (Anderson & Abrahamson, 2018). During my practice, I have witnessed at least seven deaths resulting from our staff malpractice. Studies further show that at least one in every 70 cancer cases results from misdiagnosis within the appropriate time when there are chances of getting treatment.

Still, due to late discovery, the problem escalates, making it difficult to resolve. The late discovery of the disease makes it escalate into a severe stage where the treatment process will be ineffective and costly for the patient (Carayon & Hoonakker, 2019). Therefore, caregivers must conduct proper and detailed diagnoses to minimize or eliminate misdiagnosis. It is also critical to evaluate the depth of the mistake and identify positive and effective ways to correct the issue.

Recommendation

Such problems can be prevented if health devices and technology are properly used. In the healthcare industry, the introduction of computers and other devices has greatly increased the amount of patient data stored at one time. Furthermore, continuously updating devices provides accurate prescriptions and medicine even when symptoms change (Curtis et al., 2021). With the use of technology, all patient information will be accessible, making it simple for caregivers to locate in an emergency.

Consequently, Mrs. Johnson’s condition would have been handled differently if the initial physician who attended to her case had used technology during the diagnosis procedure. If one physician cannot diagnose properly, technology assures that another can. Team collaboration is also necessary to achieve evidence-based quality improvement through sharing essential patient information for enhanced decision-making.

Conclusion

As per the case of Mrs. Johnson, medical negligence made it difficult for her to access professional assistance when she needed it the most. Doctors and patients have a role in handling the issue of medical negligence. Therefore, it is critical to formulate a functional relationship and guarantee that the issues leading to errors are resolved. The health institutions also have a role to play in ensuring improved patient outcomes.

References

Anderson, J. G., & Abrahamson, K. (2018, January). Your Health Care May Kill You: Medical Errors. In ITCH (pp. 13–17). doi 10.1007/s10729-009-9111-1.

Carayon, P., & Hoonakker, P. (2019). Human factors and usability for health information technology: old and new challenges. Yearbook of Medical Informatics, 28(01), 071-077 DOI: 10.1055/s-0039-1677907.

Cheluvappa, R., & Selvendran, S. (2020). Medical negligence-Key cases and application of legislation. Annals of Medicine and Surgery, 57, 205-211. https://doi.org/10.1016/j.amsu.2020.07.017

Curtis, N. J., Dennison, G., Brown, C. S., Hewett, P. J., Hanna, G. B., Stevenson, A. R., & Francis, N. K. (2021). Clinical evaluation of intraoperative near misses in laparoscopic rectal cancer surgery. Annals of Surgery, 273(4), 778–784. doi: 10.1097/SLA.0000000000003452

Jodal, H. C., Helsingen, L. M., Anderson, J. C., Lytvyn, L., Vandvik, P. O., & Emilsson, L. (2019). Colorectal cancer screening with fecal testing, sigmoidoscopy or colonoscopy: a systematic review and network meta-analysis. BMJ Open, 9(10), e032773. http://dx.doi.org/10.1136/bmjopen-2019-032773

Sapoelete, R., Muhadar, M., Yudianto, O., & Budiarsih, B. (2021). The Concept of Penal Mediation for the Crime of Medical Negligence in Realizing Legal Protection for Medical Personnel and Patients or Their Families. International Journal of Multicultural and Multireligious Understanding, 8(2), 147-151. DOI: http://dx.doi.org/10.18415/ijmmu.v8i2.2406

Segev, L., Kalady, M. F., & Church, J. M. (2018). Left-sided dominance of early-onset colorectal cancers: a rationale for screening flexible sigmoidoscopy in the young. Diseases of the Colon & Rectum, 61(8), 897-902. doi: 10.1097/DCR.0000000000001062

Sinha, M., Jupe, J., Mack, H., Coleman, T. P., Lawrence, S. M., & Fraley, S. I. (2018). Emerging technologies for molecular diagnosis of sepsis. Clinical Microbiology Reviews, 31(2), e00089-17. DOI:https://doi.org/10.1128/CMR.00089-17

MSN-FP6016 Assessment 1 Adverse Event or Near-Miss Analysis Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Analyze the missed steps or protocol deviations related to an adverse event or near miss.	Does not list the missed steps or protocol deviations related to an adverse event or near miss.	Lists the missed steps or protocol deviations related to an adverse event or near miss, but does not analyze how they led to the adverse event or near miss.	Analyzes the missed steps or protocol deviations related to an adverse event or near miss.	Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty where further information could improve the analysis.
Analyze the implications of the adverse event or near miss for all stakeholders.	Does not list the implications of the adverse event or near miss for all stakeholders.	Lists possible impacts of the adverse event or near miss for stakeholders, but does not analyze the short- or long-term implications.	Analyzes the implications of the adverse event or near miss for all stakeholders.	Analyzes the implications of the adverse event or near miss for all stakeholders. Identifies assumptions on which the analysis is based.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.	Does not list quality improvement technologies related to the event that are required to reduce risk and increase patient safety.	Lists quality improvement technologies related to the event that are required to reduce risk or increase patient safety, but does not evaluate how those technologies were used or could have been used more effectively.	Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety.	Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Identifies criteria by which to evaluate the technologies.
Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement.	Does not identify relevant metrics of the adverse event or near-miss incident to support need for improvement.	Attempts to identify metrics relevant to the adverse event or near-miss incident, but omits relevant data or does not show how metrics relate to the event or incident.	Incorporates relevant metrics of the adverse event or near-miss incident to support need for improvement.	Incorporates relevant metrics of the adverse event or near-miss incident to support need for improvement. Evaluates the quality of the data.
Outline an evidence-based quality improvement initiative to prevent an adverse event or near miss.	Does not outline an evidence-based quality improvement initiative to prevent an adverse event or near miss.	Attempts to outline a quality improvement initiative to prevent an adverse event or near miss, but it is not clear that all QI suggestions are evidence-based.	Outlines an evidence-based quality improvement initiative to prevent an adverse event or near miss.	Outlines an evidence-based quality improvement initiative to prevent an adverse event or near miss. Impartially considers conflicting data and other perspectives.
Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.	Does not communicate analysis and proposed initiative in a professional, effective manner; does not write clearly and logically with correct use of grammar, punctuation, and spelling.	Attempts to communicate analysis and proposed initiative professionally and effectively but there are lapses, omissions, and/or errors that detract from the overall message.	Communicates analysis and proposed initiative in a professional, effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling.	Communicates analysis and proposed initiative in a professional, effective, and error-free manner, writing clearly and logically.
Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.	Does not integrate relevant sources to support arguments; does not correctly format citations and references using APA style.	Sources lack relevance or are poorly integrated; citations or references are missing or not formatted according to APA style.	Integrates relevant sources to support arguments, correctly formatting citations and references using APA style.	Integrates relevant sources to support arguments, formatting citations and references, using APA style without errors.

Assessment 2 Quality Improvement Initiative Evaluation

Prepare an evaluation (5-7 pages) of an existing QI initiative to determine if the initiative is effective.

Introduction

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—various groups talking among themselves about results and enhancements. Nurses are critical to the delivery of high-quality, efficient health care. As a result, they must develop their skills in reviewing and evaluating performance reports. They also need to be able to communicate outcome measures related to quality initiatives effectively. Patient safety and positive institutional health care outcomes mandate collaboration among nursing staff members to ensure the integration of their perspectives in all quality care initiatives.

Overview

In the first assessment, you analyzed an adverse event or a near miss, and outlined a QI initiative to address it. This assessment will give you practice and the confidence to evaluate a quality care initiative in much the same way you might in your health care setting to help determine if the initiative is effective.

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—each group talking among themselves about results and enhancements. Because nurses are critical to the delivery of high-quality, efficient health care, it is essential that they develop the proficiency to review, evaluate performance reports, and be able to effectively communicate outcome measures related to quality initiatives. The nursing staff’s perspective and the need to collaborate on quality care initiatives are fundamental to patient safety and positive institutional health care outcomes.

Instructions; I would like you to write about the Benchmark of Hospice patients who always received enough help for pain, sadness, breathing, or constipation from the hospice care team. The link to AHRQ Dashboard is: http://datatools.ahrq.gov//nhqdr?type=subtab&tab=nhqdrnabe&count=2 Select the National Tab

Select All Topics and Measures

For Subject Area (Blue box on the Left side of the page), Select Setting of Care

For Topic, choose Home-Health Hospice

For Benchmark, choose Achieved and scroll almost to the bottom of that list.

You will see- Hospice patients who always received enough help for pain, sadness, breathing, or constipation from the hospice care team.

Instructions:

Imagine you have been asked to prepare and deliver an analysis of an existing QI initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you. Alternatively, you may use the hospice information provided in the Vila Health: Data Analysis activity in this assessment. (You will use this; please see attached documents).

The report aims to assess whether the specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your target audience is nurses and other health professionals with specializations or interests in your chosen condition, disease, or public health issue.

In your report, you will:

Analyze a current QI initiative in a healthcare setting.

Identify what prompted the implementation of the QI initiative.

Evaluate problems that arose during the initiative or problems that were not addressed.

Evaluate the success of a current QI initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.

Identify the core performance measurements related to successful treatment or management of the condition.

Evaluate the impact of the quality indicators on the healthcare facility.

Incorporate interprofessional perspectives related to the success of actions used in the QI initiative as they relate to functionality and outcomes.

Recommend additional indicators and protocols to improve and expand outcomes of a current quality initiative.

Ensure your analysis conveys purpose in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure to address all of the bullet points. You may also want to read the Quality Improvement Initiative Evaluation Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Quality Improvement Initiative Evaluation [DOCX] (please see attached document) document for additional clarification about things to consider when creating your assessment.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page and References section.

Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance.

APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 2: Plan quality improvement initiatives in response to routine data surveillance.

Recommend additional indicators and protocols to improve and expand outcomes of a quality initiative.

Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures. Analyze a current quality improvement initiative in a health care setting.

Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.

Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work life quality.

Incorporate interprofessional perspectives related to the success of actions utilized in a quality improvement initiative as they relate to functionality and outcomes.

Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Hospice Data 2020-2021

Facility metrics related to four AHRQ reportable benchmarks.

Benchmark Category

2020

2021

Hospice patients whose hospice care team always treated them with dignity and respect and really cared about them

78%

80%

Hospice patients whose hospice care team always communicated well with their family caregivers about taking care them

78%

75%

Hospice patients who always received enough helps for pain, sadness, breathing, or constipations from hospice care team

65%

68%

Hospice patients and family caregivers who always got help as soon as they need from hospice care team

70%

68%

Monthly Reporting – Hospice Unit

Monthly Reporting – Hospice Unit Per Vila Health policy, these figures include patient reports each month for the 4 reportable benchmarks.

Hospice Data (2020)
Total Hospice patients for the year = 121	January	February	March	April	May	June	July	August	September	October	November	December	Total
Hospice patients whose hospice care team always treated them with dignity and respect, and really cared about them	7	12	10	3	7	11	0	6	9	8	10	11	94
Hospice patients whose hospice care team always communicated well with their family caregivers about taking care them	8	10	2	11	12	3	4	4	7	11	13	9	94
Hospice patients who always received enough helps for pain, sadness, breathing, or constipations from hospice care team	3	12	11	7	5	2	8	9	10	5	3	4	79
Hospice patients and family caregivers who always got help as soon as they need from hospice care team	11	2	4	10	10	7	0	10	7	6	12	5	84
													351
Hospice Data (2021)
total Hospice patients for the year = 130	January	February	March	April	May	June	July	August	September	October	November	December	Total
Hospice patients whose hospice care team always treated them with dignity and respect, and really cared about them	7	8	8	9	8	8	8	9	11	12	8	8	104
Hospice patients whose hospice care team always communicated well with their family caregivers about taking care them	9	8	5	8	8	9	9	7	8	8	8	9	96
Hospice patients who always received enough helps for pain, sadness, breathing, or constipations from hospice care team	7	6	5	7	7	8	8	8	9	6	7	10	88
Hospice patients and family caregivers who always got help as soon as they need from hospice care team	5	6	7	8	7	7	9	8	8	10	7	6	88
													376

Grading Rubric

This assignment (Assignment #2) is a continuation of Assignment 1

For DISTINGUISHED:

Analyzes a current quality improvement initiative in a health care setting, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).

Evaluates the success of a current quality improvement initiative through recognized national, state, or accreditation benchmarks and outcome measures. Identifies assumptions on which the analysis is based.

Incorporates interprofessional perspectives and actions related to initiative functionality and outcomes, and identifies areas of uncertainty, knowledge gaps, and additional information that would be needed to gain a more complete understanding

Recommends additional indicators and protocols to improve and expand outcomes of a quality initiative, and impartially explains the pros and cons of these recommendations.

Quality Improvement Initiative Evaluation Example

Quality of care is a profound, multifactorial concept that defines practices, policies, and initiatives of global healthcare systems. Although ensuring care quality is an overarching goal for healthcare organizations and professionals, it is a daunting endeavor to provide care services that address all dimensions of quality care. According to Keßler & Heidecke (2017), factors that define the quality of care are process safety, effectiveness, patient-centeredness, timelines, equity, and efficiency.

Amidst the determination to achieve all these dimensions of quality care, healthcare professionals encounter various challenges that compromise service delivery and expose patients to multiple safety threats. Hospital-acquired infections (HAIs) are among the major threats to patient safety and care quality. Asfaw (2021) argues that hospital-acquired infections pose a significant health and safety threat to hospitalized patients by perpetuating multiple adverse consequences, including increased mortality rates, prolonged hospitalization, and increased care costs.

Examples of HAIs are catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia (VAP) (Centers for Disease Control and Prevention, 2019). This paper provides an analysis of an organizational-level quality improvement initiative for preventing hospital-acquired infections.

Analyzing a Current Quality Improvement Initiative in a Healthcare Setting

Our organization has a functional policy and quality improvement program for preventing and controlling hospital-acquired infections. This policy focuses on a bundled model that has various strategies and procedures, including hand washing protocol, cleansing of urethral meatus before catheter insertion, wearing personal protective equipment (PPEs), the use of CHG sponge (chlorhexidine gluconate impregnated dressings), and patient bath using antiseptics.

According to Puro et al. (2022), healthcare facilities can prevent hospital-acquired infections by implementing effective infection prevention and control (IPC) measures that focus on collaboration among healthcare professionals, widespread diffusion across hospital units, and shared knowledge. As a result, healthcare professionals in our organization have emphasized the use of a bundled model in preventing hospital-acquired infections, especially after the COVID-19 pandemic.

Identifying Factors that Prompted the Implementation of the Quality Improvement Initiative

The major factor that informed the need to implement a contingency plan for preventing hospital-acquired infections is the overarching objective of safeguarding patient safety by addressing threats to clients’ health and wellness. Our organization shares the mission of improving individual and community health by emphasizing collaborative and evidence-based practices. Equally, the emergence of the COVID-19 pandemic as a highly transmissible viral infection prompted the implementation of urgent, yet evidence-based approaches for preventing the disease transmission and progression.

Baker et al. (2021) contend that COVID-19 contributed massively to improving organizational interventions for infection prevention and control. In this sense, healthcare facilities embarked on hand washing protocols, training employees on donning and doffing of personal protective equipment, compliance with contact precautions, and improving hygiene standards through environmental disinfection. Our hospital was not an exception to the impacts of the COVID-19 pandemic on institutional measures for preventing and controlling infections.

Problems that Arose During the Initiative

Although our institution has a functional quality improvement initiative for preventing and controlling infections, various challenges emerge during the enactment of an organizational-wide bundled plan. These problems are nursing staff shortages, healthcare professionals’ unfamiliarity with new approaches for containing the COVID-19 pandemic, and resource issues.

Lowe et al. (2021) contend that inadequate hospital infrastructure, a lack of in-service training, supply chain distributions, high infection rates, and many patients needing timely care interventions are challenges that compromise interventions for preventing and controlling hospital-acquired infections. During the COVID-19 pandemic, our hospital grappled with overcrowding, overwhelmed departments, nursing staff shortages, and time pressures that affected the implementation of the quality improvement initiative.

Recognized Benchmarks and Outcome Measures as Required to Meet National, State, or Accreditation Requirements

Healthcare facilities can track benchmarks and outcome measures for hospital-acquired infections by using data from the National Healthcare Safety Network (NHSN). According to Healthy People 2030 (n.d.), the NHSN collects data from over 37000 healthcare facilities in all states. Our organization is among health facilities that use data from the National Healthcare Safety Network to track and report hospital-acquired infections.

The data obtained from over 37000 health facilities enables the NHSN to establish a national, state, and local benchmarks for hospital-acquired infections. According to the National Healthcare Safety Network [NHSN] (2022), healthcare institutions can calculate the rate of HAIs, including catheter-associated urinary tract infections [CAUTI) by dividing the number of CAUTIs by the number of catheter days and multiplying the result by 1000. Further, the NHSN argues that CAUTI rates range from 0.0 per 1000 catheter days to 35.3 per 1000 catheter days depending on various considerations, including location types, bed size, and type of medical school affiliated with the facility.

Our hospital’s performance has been consistently unconvincing when using the NHSN recommendations for CAUTI rates as the guiding benchmark. Over the last two years, the facility has maintained an average CAUTI rate of 33 per 1000 catheter days, creating a sense of urgency for the implementation of evidence-based quality improvement initiatives.

Equally, a high rate of HAIs has resulted in financial consequences for the hospital. For instance, Vokes et al. (2018) argue that the Center for Medicare and Medicaid Services (CMS) implements the Value-based purchasing (VBP) program and the Hospital-acquired condition reduction program that reduce reimbursement by 1% for healthcare facilities whose performances fall in the worst 25% of hospitals for HAC metrics. Our hospital is at risk of enduring these financial regulations and deductions.

Core Performance Measurements Related to Successful Treatment or Management of the Condition

The hospital can use various core performance measurements to assess the effectiveness of a quality improvement initiative for preventing and controlling hospital-acquired infections (HAIs). Examples of these measures include compliance with the use of personal protective equipment (PPEs), adherence to hand hygiene protocols, effective environmental risk assessments, development of comprehensive patient safety guidelines, in-service training programs for healthcare professionals, safer working systems, and approaches for reporting, managing, and analyzing incidents of hospital-acquired infections. These core performance measurements are consistent with the Donabedian model for care quality that focuses on synergistic relationships between organizational structure, process, and outcome measures.

The Impact of the Quality Indicators on the Healthcare Facility

Quality indicators of a contingency plan for preventing and controlling hospital-acquired infections include improved adherence to hand hygiene, the development of comprehensive clinical guidelines for ensuring patient safety, in-service training and education programs, and the implementation of safer working systems. These indicators emphasize the synergistic relationships between organizational structure, process, and outcome measures (Binder et al. 2020).

Consequently, they influence team perspectives of care quality, encourage the healthcare facility to invest massively in interventions to prevent adverse events like hospital-acquired infections, and establish the rationale for improving employees’ knowledge and awareness of quality improvement initiatives through education and in-service training.

Interprofessional Perspectives Related to the Success of Actions Used in the Quality Improvement Initiative

Teamwork and interprofessional collaboration are profound aspects of enhancing the effectiveness of a quality improvement initiative for preventing and controlling hospital-acquired infections. The Joint Commission (2022) documents a compendium of updated strategies for preventing healthcare-associated infections. These advanced approaches include synthesizing the best evidence to prevent infections and emphasizing individual and group accountability in implementing infection prevention practices.

In this sense, a team-based approach to effective prevention and control of HAIs consolidates inputs and knowledge from physicians, nurses, nurse assistants, and other healthcare stakeholders to facilitate the enactment of evidence-based practices, including periodic in-service training, development of clinical guidelines for urinary catheter insertion, maintenance, and removal, environmental hygiene, and timely reporting and communication of adverse incidents.

Additional Indicators and Protocols to Improve and Expand Outcomes of the Current Quality Initiative

The hospital can strengthen the current quality improvement initiative for HAIs prevention and control by implementing various additional indicators and protocols. Vokes et al. (2018) recommend horizontal and vertical interventions, including active detection of infections, development of safety checklists that emphasize risk reduction, change implementation, and environmental modification strategies like fitting clinical rooms with copper alloy surfaces to prevent infections. Equally, educating healthcare professionals, implementing a laboratory-based alert system, using single occupancy rooms, and improving infection surveillance reporting systems are profound approaches for enhancing and expanding outcomes of the current healthcare Initiative.

Conclusion

Healthcare-associated infections (HAIs) pose a significant health concern by increasing the mortality rate, inflicting a massive economic burden on healthcare systems, and compromising patient safety. Although our hospital has a functional policy and quality improvement initiative for HAIs, it is essential to address problems that manifest when actualizing contingency plans.

The proven options for improving and expanding outcomes of the current quality initiative for HAIs prevention and control are emphasizing in-service training and education, enhancing infection surveillance using advanced technologies, including laboratory-based alert systems, implementing single occupancy rooms policy to prevent overcrowding, and analyzing the best evidence to inform decisions and practices.

References

Asfaw, N. (2021). Knowledge and practice of nurses towards prevention of hospital-acquired infections and its associated factors. International Journal of Africa Nursing Sciences, 15, 100333. https://doi.org/10.1016/j.ijans.2021.100333

Binder, C., Torres, R. E., & Elwell, D. (2020). Use of the Donabedian model as a framework for COVID-19 response at a hospital in suburban Westchester County, New York: A facility-level case report. Journal of Emergency Nursing, 47(2). https://doi.org/10.1016/j.jen.2020.10.008

Centers for Disease Control and Prevention. (2019). Types of healthcare-associated infections. https://www.cdc.gov/hai/infectiontypes.html

Healthy People 2030. (n.d.). National Healthcare Safety Network (NHSN). Retrieved November 26, 2022, from https://health.gov/healthypeople/objectives-and-data/data-sources-and-methods/data-sources/national-healthcare-safety-network-nhsn

Keßler, W., & Heidecke, C.-D. (2017). Dimensions of quality and their increasing relevance for Visceral Medicine in Germany. Visceral Medicine, 33(2), 119–124. https://doi.org/10.1159/000462997

Lowe, H., Woodd, S., Lange, I. L., Janjanin, S., Barnett, J., & Graham, W. (2021). Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: A qualitative study. Conflict and Health, 15(1). https://doi.org/10.1186/s13031-021-00428-8

National Healthcare Safety Network. (2022). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) events (pp. 1–18). https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf

Puro, V., Coppola, N., Frasca, A., Gentile, I., Luzzaro, F., Peghetti, A., & Sganga, G. (2022). Pillars for prevention and control of healthcare-associated infections: An Italian expert opinion statement. Antimicrobial Resistance & Infection Control, 11(1). https://doi.org/10.1186/s13756-022-01125-8

The Joint Commission. (2022). Compendium of strategies to prevent healthcare-associated infections. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/compendium-of-strategies-to-prevent-healthcare-associated-infections/

Vokes, R. A., Bearman, G., & Bazzoli, G. J. (2018). Hospital-acquired infections under pay-for-performance systems: An administrative perspective on management and change. Current Infectious Disease Reports, 20(9). https://doi.org/10.1007/s11908-018-0638-5