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DQ8 Case Study: Chapter 14

DQ8 Case Study: Chapter 14

DQ8 Case Study: Chapter 14

Medical Errors: An Ongoing Threat To Quality Health Care

A nurse manager is reviewing occurrence reports of medical errors over the last six months. The nurse manager knows that medical errors are not the only indicator of quality of care. They are, however, a pervasive problem in the current health care system and one of the greatest threats to quality health care. The nurse manager is putting together a list of possible solutions to decrease the number of occurrences of medication errors. DQ8 Case Study: Chapter 14

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1. Recognizing that health care errors affect at least one in every 10 patients around the world, the World Health Organization’s World Alliance for Patient Safety and the Collaborating Centre identified priority program areas related to patient safety. What are the patient safety program areas the nurse manager should consider for implementation?

2. Describe the Joint Commission 2017 National Patient Safety Goals for Hospitals.

3. Discuss the Institute of Medicine’s four-pronged approach to reducing medical mistakes?

Please use the numbers of questions in the paper.

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    Chapter_14.pptx

    Chapter 14 Medical Errors: An Ongoing Threat to Quality Health Care

     

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    Definitions

    Medical errors: adverse events that could have been prevented given current state of medical knowledge

    Medication error: preventable event causing or leading to inappropriate medication use or patient harm

    Medication in control of health care professional, patient, or consumer

    Adverse events: adverse changes in health occurring as a result of treatment

    Adverse drug event when medications involved

     

     

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    Seminal Research and Medical Errors #1

    Benchmark study by Brennan et al. (1991)

    Study by Thomas et al. (1999)

    Study by Leape et al. (1991 and 1994)

     

     

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    Seminal Research and Medical Errors #2

    “To Err Is Human” by the Institute of Medicine (IOM)

    Death due to medical errors: possibly eighth leading cause of death in 1999

    More people die yearly from medical errors than from motor vehicle accidents, breast cancer, or AIDS

    Examination of types of errors: adverse events with pharmaceutical agents (potentially preventable)

    Studies confirming IOM figures

    Confirmation of scope of medical errors in follow-up report by IOM

     

     

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    Seminal Research and Medical Errors #3

    IOM recommendations:

    National goal to reduce medical errors by 50% over 5 years

    Four-pronged approach to reducing medical mistakes nationwide (see Box 14.1)

    National focus

    Identification of, and learning from, errors

    Elevation of standards, expectations for improvement

    Implementation of safe practices

     

     

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    Question #1

    Is the following statement true or false?

    Adverse events result from treatment.

     

     

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    Answer to Question #1

    True

    Adverse events are defined as adverse changes in health that occur as a result of treatment.

     

     

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    Work to Achieve IOM Goals #1

    Quality Interagency Coordination Task Force (1998)

    Coordination of federal agencies providing health care services

    Evaluation of IOM recommendations

    Development of strategies for identifying threats to patient safety, reducing medical errors

    Final report delivered in February 2000

     

     

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    Work to Achieve IOM Goals #2

    National Forum for Health Care Quality Measurement and Reporting (2017)

    The National Quality Strategy: Aims, Priorities, and Levers

    Aims

    Better care

    Healthy people/Healthy communities

    Affordable care

     

     

     

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    Work to Achieve IOM Goals #3

    The National Quality Strategy: Aims, Priorities, and Levers (see Box 14.3)

    Six priorities

    Eight levers

     

     

     

     

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    Work to Achieve IOM Goals #4

    Joint Commission 2017 National Patient Safety Foundation (see Box 14.4)

    Improve patients correctly

    Improve staff communication

    Use medicines safely

    Use alarms safely

    Prevent infection

    Identify patient safety risks

    Prevent mistakes in surgery

     

     

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    Work to Achieve IOM Goals #5

    The Joint Commission

    Comprehensive database of sentinel events

    Root cause analysis; Sentinel Events Policy

    Failure mode and effects analysis (FMEA)

     

     

     

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    Work to Achieve IOM Goals #6

    Centers for Medicare and Medicaid Services (formerly HCFA)

    Medicare Quality Initiatives

    Pay for Performance (quality-based purchasing)

    Physician Quality Reporting Initiative; became Physician Quality Reporting System with passage of Affordable Care Act of 2011

    PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (Quality Payment Program, 2017)

     

     

     

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    Work to Achieve IOM Goals #7

    Centers for Medicare and Medicaid Services (formerly HCFA)

    Medicare Improvements for Patients and Providers Act (2008)

    “Never events” (see Box 14.5)

     

     

     

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    Work to Achieve IOM Goals #8

    Institute for Healthcare Improvement

    Highlighting of evidence-based best practices

    Disciplined research and development processes, prototyping projects

    Facilitation of further research, adaptation, and adoption of quality improvement strategies

    Health care report cards

     

     

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    Question #2

    The National Priorities Partnership evolved out of which of the following?

    A. Quality Interagency Coordination Task Force

    B. Centers for Medicare and Medicaid Services

    C. National Forum for Health Care Quality Measurement and Reporting

    D. The Floyd D. Spence National Defense Authorization Act of 2001

     

     

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    Answer to Question #2

    C

    The National Priorities Partnership developed from the work of the National Forum for Health Care Quality Measurement and Reporting.

     

     

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    Culture of Safety Management

    Patient safety: one of nation’s most pressing challenges

    Mandate for every health care organization

    IOM final recommendation: implementation of safe practices at delivery level

     

     

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    Six Sigma Approach

    Culture of safety management at institutional level

    Sigma: statistical measurement reflecting product or process performance

    Higher sigma values = better performance

    Historically, health care aiming for three-sigma processes instead of six

     

     

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    Mandatory Reporting of Errors

    Mandatory reporting system for medical errors, adverse events at national, state levels

    As of 2014, at least 26 states requiring hospitals and/or other medical facilities to report serious medical errors

    Need for increased mandatory reporting at institutional level and by individual providers

    Possible fear of legal suits or disciplinary measures as barrier for greater disclosure and reporting

     

     

     

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    Legal Liability and Medical Error Reporting

    Medical liability system + litigious society: potential barriers to systematic efforts to uncover, learn from mistakes

    Patient Safety Improvement Act (2002)

    Patient Safety and Quality Improvement Act of 2005

    Proposed federal legislation to protect voluntary reporting of ordinary injuries, “near misses”

     

     

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    Leapfrog Group

    Need for implementation of evidence-based standards such as

    Computerized physician (or prescriber) order entry (CPOE)

    Leapfrog developed evaluation tool

    Evidence-based hospital referral (EHR)

    Intensive-care-unit physician staffing (IPS)

     

     

     

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    Question #3

    Is the following statement true or false?

    A sigma value of three indicates lower performance than a sigma value of five.

     

     

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    Answer to Question #3

    True

    A sigma value is a statistical measurement that reflects performance. Thus, the higher the sigma value, the better the performance.

     

     

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    Bar Coding Medications

    Reduction in point-of-care medication errors

    National drug code number for all prescription, OTC meds used in hospitals

    Bar coding + CPOE = increased ability to follow “five rights” of medication admin

     

     

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    Changing Organizational Culture

    Quality and Safety Education for Nurses (QSEN) project

    Knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care system

    KSA—better able to identify potential errors and intervene before errors occur

    Organizational cultures needing to remove blame from individual and focus on how organization can be modified to reduce likelihood of errors

    “Just culture” or “culture of safety management”

     

     

     

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    Patient Safety Solutions

    WHO’s Word Alliance for Patient Safety and the Collaborating Centre packaged nine effective solutions called patient safety solutions to reduce health care errors

    WHO (2017) initiated its third Global Patient Safety Challenge: Medication Without Harm

    See Box 14.6

     

     

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    Question #4

    Which of the following would most likely be most significant in promoting a culture of safety management?

    A. Mandatory reporting of errors

    B. Six Sigma approach

    C. Bar coding meds

    D. Removal of blame

     

     

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    Answer to Question #4

    D

    Although mandatory reporting of errors, a Six Sigma approach, and bar coding meds are important in promoting a culture of safety management, perhaps the most significant change that must occur is that organizational cultures must be created that remove blame from the individual and focus on how the organization can be modified to reduce the likelihood of errors occurring in the future. DQ8 Case Study: Chapter 14

     

     

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    End of Presentation

     

     

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