A Case Study For Patient Care Assignment

A Case Study For Patient Care Assignment

Need Help Writing an Essay?

Tell us about your assignment and we will find the best writer for your paper

Write My Essay For Me

A Case Study QI in Patient Care

Providing high-quality care is every patient’s right, and healthcare providers should ensure that their patients receive the best treatment. However, this sometimes is never the case, as some patients suffer from negligence or act of unprofessionalism from healthcare workers (Gates et al., 2019)A Case Study For Patient Care Assignment. Consequently, patients suffer the consequences, some of which are lethal and cause significant morbidity and fatality. Therefore, healthcare providers need to maintain high professionalism while delegating their duties.

ORDER A PLAGIARISM-FREE PAPER HERE

Description of Error

During my pediatric rotation in a renowned hospital, I observed a child, probably seven years of age, going into respiratory arrest due injection of a high dosage of morphine. The student nurse on that particular shift injected the child with 10 mg of morphine instead of 100 micrograms to manage pain caused by painful crisis in sickle cell disease. After a short while, the child started gasping for air with labored breathing. Soon afterwards, the child went into respiratory arrest with no breathing activities observed. The student nurse informed the nurse in charge, and soon a team gathered and started performing cardiopulmonary resuscitation while administering naloxone. After several attempts, the child started gasping for air, which was supplemented by administering 100% via a bag valve mask A Case Study For Patient Care Assignment.

Chain of Events

The chain of events leading to the error can be traced from the physician who prescribed the medication to the patient. During medical ward rotation, the attending physician recommended that the patient should receive morphine for management of painful crisis that the patient presented with and verbally ordered the medical intern, who subsequently also ordered the student nurse verbally what was to be done. The student nurse was new the department; hence she lacked the necessary experience. The nurse failed to dilute the 10 mg/ml of morphine and injected it directly since she wanted to finish her shift urgently and rush somewhere. Seniors nurses were busy on their phones, and there was no one to assist the student nurse.

Root Cause Analysis and Factors Leading to the Error

In the scenario discussed, a root cause analysis was conducted, and effective measures were implemented to prevent the recurrence of similar events. Morphine is an opioid that provides strong analgesic properties for pain management. It is highly recommended in sickle cell patients to manage the severe pain caused by painful, vasoocclusive and sequestration crises (Haggerty et al., 2020). The recommended dosage of morphine is 100 micrograms. High dosage of morphine causes respiratory arrest due to suppression of respiratory centers in the brain (Montandon & Slutsky, 2019)A Case Study For Patient Care Assignment.

Verbal communication also contributed to the error. Root cause analysis requires that all prescriptions be documented properly to avoid any confusion that may arise. Therefore, healthcare providers should properly write down the prescription or record the data electronically to prevent such incidents from recurring. Therefore, verbal communication should be avoided at all costs. If it is a must, the nurse administering the drug should ensure that she understands all the details involving reconstitution and administration of morphine.

Causes Prioritized

The most important cause of the error was the administration of the wrong dosage of morphine, in this case, 10 mg, by the student nurse with no drug administration experience. Secondly, the nurse was in a hurry to complete her shift which may have prevented her from seeking guidelines for administering the drug. She, therefore, administered the drug in a hurry without considering the actions of her consequences. Thirdly, the senior nurses were busy on their phones and were not interested in what the attending nurse was doing. Lack of disinterest made the student nurse administer the drug without supervision since she was new in the department. Lastly, morphine administration chart pinned on the wall was torn and faded.

Changes Needed to Prevent Recurrence

Based on the root analysis cause, radical changes are needed to prevent the incident from occurring again. Firstly, the hospital should formulate a standardized policy regarding the administration of morphine in pediatrics department. The policy should ensure that only qualified and experienced healthcare personnel should administer the drug. In cases where inexperienced nurse administers the drug, there should be constant supervision from experienced nurses. Also, the policy should lay the algorithm for administration procedure, including dosage calculation and reconstitution. The algorithms should be printed and pinned as charts on the ward walls to act as references. There should be regular maintenance of torn and faded charts A Case Study For Patient Care Assignment.

The policy needs to ban the use of verbal communication to pass information regarding patient management. Verbal communication is prone to errors. The details of the prescription should be clearly hand-written or recorded electronically. Documented data is a source of evidence, and healthcare providers can be held accountable for their actions. Documented data also acts as a reference when someone forgets the information, hence minimizing the chances of medical errors. Finally, experienced nurses should always be available to assist their juniors and participate in managing the patients.

Most Important Factor that Led to the Error

The most important factor that led to the error was the delegation of duty to an inexperienced nurse rushing to complete her shift. The nurse had no background knowledge of reconstitution and administration of morphine. The subsequent events that followed after administering 10 mg of morphine almost cost the life of the patient. Morphine reconstitution and administration is a technique that requires expertize, and any errors can predispose the patients to severe adverse drug reactions (Toce et al., 2020)A Case Study For Patient Care Assignment. Though rare, errors in morphine drug administration cause significant morbidity and mortality.

Plan for Improvement using the Plan Do Study Act Approach

The two departments, pharmacy and pediatric, should plan effective means of ensuring correct dispensation and dosage administration. Pharmacists should formulate policies to ensure that drugs such as morphine are only given to qualified healthcare workers and provide clear instructions on usage (Bryl et al., 2021)A Case Study For Patient Care Assignment. The healthcare workers, especially experienced nurses, should countercheck the dosage of morphine before it is administered by junior nurses, who, in most cases, are not experienced. Also, pharmacists to dispense morphine to experienced healthcare workers.

ORDER  HERE

Positive changes were observed after the incident as nurses administered the correct dosages of morphine. There was constant supervision of junior nurses by their seniors while administering drugs. Pharmacists also dispensed morphine to qualified, experienced healthcare workers. Based on the success of the interventions, it was recommended that changes instituted should be continued to prevent future recurrences. Senior nurses maintained constant supervision and guidance to junior nurses.

Conclusion

Medical errors cause significant threats to the lives of patients. Effective interventions should be put in place to prevent recurrence of medical errors. Healthcare system that is organized in terms of responsibilities of different team members record less incidence of medical errors. Significant morbidity and mortality have been reported as a result of medical errors.

References

Bryl, A. W., Demartinis, N., Etkin, M., Hollenbach, K. A., Huang, J., & Shah, S. (2021). Reducing opioid doses prescribed from a pediatric emergency department. Pediatrics, 147(4). https://doi.org/10.1542/peds.2020-1180

Gates, P. J., Baysari, M. T., Gazarian, M., Raban, M. Z., Meyerson, S., & Westbrook, J. I. (2019). Prevalence of medication errors among paediatric inpatients: systematic review and meta-analysis. Drug Safety, 42, 1329-1342.

Haggerty, A. G., Koons, A., Beauchamp, G., Cook, M. D., Cannon, R. D., & Katz, K. D. (2020). Opioid-Induced Sickle Cell Crisis With Multiple, Life-threatening Complications. Journal of Osteopathic Medicine, 120(11), 770-773. https://doi.org/10.7556/jaoa.2020.125

Montandon, G., & Slutsky, A. S. (2019). Solving the opioid crisis: respiratory depression by opioids as critical end point. Chest, 156(4), 653-658. https://doi.org/10.1016/j.chest.2019.05.015

Toce, M. S., Michelson, K., Hudgins, J., Burns, M. M., Monuteaux, M. C., & Bourgeois, F. T. (2020). Association of state-level opioid-reduction policies with pediatric opioid poisoning. JAMA pediatrics, 174(10), 961-968. A Case Study For Patient Care Assignment

Assignment QI in Patient care: A Case Study
QI in Patient Care: A Case Study
Note: A lot of case studies can be found here: https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/default.aspx

You will describe a patient situation in which there was an adverse event or a near miss—i.e. a quality of care failure due to an error in some aspect of the patient care. This can be something you have seen yourself or that you found online. The case study should have the following details:

A patient related situation happened that either injured the patient or had a high probability of injuring the patient (a near miss).
There is a chain of events leading to the injury or near miss.
One or more errors happened in that chain of events. An example of a chain of events is the following: “The doctor wrote a correct drug order, the pharmacist didn’t read the order carefully and sent up the wrong drug, and then the nurse didn’t check to see it was the wrong drug and administered it to the patient. As a result, the patient suffered a cardiac event and had to be transferred to the Intensive Coronary Care Unit. The patient survived, but just barely.”
The situation is interdisciplinary and relies on a team approach for improvement. (In the example above, both nursing and the pharmacy are involved
Based on this case study, you review and analyze this case and discuss it within your teams. Your discussion should include the following: A Case Study For Patient Care Assignment
Analyze your patient case using root cause analysis
Identify the factors that contributed to the error, and specify which were most important to the error happening. Remember, most errors are at least partially caused by problems with the care delivery system or other systems
Based on the errors you found, identify one or more changes that must be made to prevent the error from happening again or at least make it much less likely.
Prioritize the changes needed. The first change should focus on the factor most important as a cause of the error. Other changes that might also need to be made (recognizing that once the most important cause is addressed some of the other factors might not still exist). Remember, educational interventions are appropriate ONLY when you have assessed the people involved and found the cause to be a lack of knowledge. Frankly, this isn’t often the problem.
Develop a plan for making the first change and note if that will eliminate any other causes. Remember to include information on how two or more departments or disciplines will have to collaborate on how to correct the problem.

Write a paper with the above information. The paper will be in APA format and no more than 6 pages, not including title and reference pages. This assignment is due at the end of Unit 3.

Follow the Grading Rubric below to ensure all required areas are covered in your paper.

QI Case Study Paper Rubric and Writing guide

Criteria

Possible Points

Earned Points

Description of the error that occurred

10

Chain of events leading to the error

10

Root Cause analysis and factors leading to the error

20

Causes prioritized

15

Changes needed to prevent the error from happening again

10

Identification of the most important factor that led to the error

10

Plan for improvement (correction of first factor leading to the error) using the Plan Do Study Act approach

20

APA Format

5

Total Points

100

https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/default.aspx

Assignment QI in Patient care: A Case Study

QI in Patient Care: A Case Study
Note:  A lot of case studies can be found here:  https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/default.aspx

You will describe a patient situation in which there was an adverse event or a near miss—i.e. a quality of care failure due to an error in some aspect of the patient care. This can be something you have seen yourself or that you found online. The case study should have the following details: A Case Study For Patient Care Assignment

1. A patient related situation happened that either injured the patient or had a high probability of injuring the patient (a near miss).
2. There is a chain of events leading to the injury or near miss.
3. One or more errors happened in that chain of events.  An example of a chain of events is the following: “The doctor wrote a correct drug order, the pharmacist didn’t read the order carefully and sent up the wrong drug, and then the nurse didn’t check to see it was the wrong drug and administered it to the patient.  As a result, the patient suffered a cardiac event and had to be transferred to the Intensive Coronary Care Unit.  The patient survived, but just barely.”
4. The situation is interdisciplinary and relies on a team approach for improvement. (In the example above, both nursing and the pharmacy are involved
5.  Based on this case study, you review and analyze this case and discuss it within your teams.  Your discussion should include the following:
6. Analyze your patient case using root cause analysis
7. Identify the factors that contributed to the error, and specify which were most important to the error happening.  Remember, most errors are at least partially caused by problems with the care delivery system or other systems
8. Based on the errors you found, identify one or more changes that must be made to prevent the error from happening again or at least make it much less likely.
9. Prioritize the changes needed. The first change should focus on the factor most important as a cause of the error. Other changes that might also need to be made (recognizing that once the most important cause is addressed some of the other factors might not still exist). Remember, educational interventions are appropriate ONLY when you have assessed the people involved and found the cause to be a lack of knowledge. Frankly, this isn’t often the problem.
10. Develop a plan for making the first change and note if that will eliminate any other causes. Remember to include information on how two or more departments or disciplines will have to collaborate on how to correct the problem.
    

    ORDER TODAY

Write a paper with the above information. The paper will be in APA format and no more than 6 pages, not including title and reference pages. This assignment is due at the end of Unit 3.

Follow the Grading Rubric below to ensure all required areas are covered in your paper.

A Case Study For Patient Care Assignment