Risk Management Package to Use in Practice: Hand- Washing in the Healthcare Setting - Term Paper Example

A Report and Risk Management Package to Use in Practice Introduction: Healthcare policy throughout the world, specially in UK is now extremely rigorous about improvement of quality of healthcare. Discrepancies of quality of care may arise from errors in execution of care in most healthcare systems (Department of Health, 1998). This resulted in origins of policies of clinical governance with the aim of improvement in quality of care (Moss, F., Palmberg, M., and Plsek, P., 2000). The deployment of clinical governance for efficient risk management was due, moreover, to consumer-oriented social changes that demands greater accountability and professionalism from the personnel that execute care (Seddon, M.E., Marshall, M.N., and Campbell, S.M., (2001). In the real setting of delivery of healthcare, this would indicate a policy to follow in implementation of healthcare delivery procedure to avoid adverse incidents in medical practice (Leape, L.L. and Berwick, D.M., 2000). The most scientific approach, hence, would be to manage and monitor the quality of healthcare delivered, and clinical governance represents an organization-wise strategy for improving quality within National Health Service in UK. Translated into quality management terms, this would mean devotion to and implementation of a process that involves recording, reporting, managing, and investigating an adverse event and ability to learn from that (Department of Health, (2000). Since the goal of quality in healthcare is to ensure patient and staff safety, these incidents that threaten this safety are known as risks. Any risk management package, therefore, will consist of a written description of the procedure to serve as the standard with clearly demarcated areas of responsibilities of the involved personnel; if there is such an incident, a process to classify, a protocol for analysis and investigation protocol; a policy of informatics to both the patient and staff with a positive and fair blame approach; guidelines for management of care and service delivery more efficiently; and most importantly, learning from these incidents (Moss, F., Palmberg, M., and Plsek, P., 2000). Therefore, clinical governance is a framework to improve quality of service through quality assurance and quality improvement. By initiatives designed to ensure minimum standards of existing care, the system ensures accountability. This, as a result, will serve as a mechanism to identify and to deal with the personnel whose standards do not match the stated standards of practice. On the other hand, quality improvement refers to approaches that attempt to improve care and to prevent poor care to safeguard standards and improve quality of care. There are many risks that may compromise healthcare in the hospital setting, and recognition of these risk factors only would lead to an efficient management of those risks. Any risk management programme would assist the staff in identification and management of potential risks in implementation of clinical programme (Thomson, R., 1998). The guidelines would also provide the staff with tools to identify, analyse, and manage risks of any nature. One can take the example of cross infection. Hospitalized patients are more prone to develop infections that are acquired from the hospital environment. Microorganisms are known to flourish in the healthcare setting and often known to break in the infection control procedures and practices. Combined with a patient's weakened defense mechanisms, a breach in the practice and procedure sets the stage ready for nosocomial infections (Boyce, J.M., 1999). The effect of nosocomial infections can be far reaching with respect to the client in that it increases morbidity and mortality, and to control that, the patient's stay is much prolonged. The effect on the economics of the hospital authority is easily conceivable. In addition, diagnosis and treatment of these infections can be an additional burden on the healthcare budget and cane be a source of intense pressure on the health services (Ayliffe, G., Lobury, E., Gedded, A., and Williams, J., 1995). If risk management involves control of cross infection, the true nature of the risk will be evident from chain of infection that includes the microorganism, the infectious reservoir, the portal of exit from the reservoir, the mode of transmission, portal of entry into the host, and the susceptible host. Understanding of these links is important since measures to break these links would prevent cross infection. The microorganisms that are acquired from the external sources usually come from reservoirs that abound in healthcare settings (The Infection Control Nurses Association (ICNA), 2003). These reservoirs may include patients, visitors, staff, equipments, and many other sources. Most human reservoirs that cause cross infection in this setting would be carriers, since the presence of infection in them is not manifest in the form of signs or symptoms of disease. Asymptomatic carriers pose risks of transmission to susceptible patients admitted in the ward settings because the presence of infection go unnoticed, and appropriate precautions are often lacking. The portal of exit from the carrier may be many; it may be through respiratory, genitourinary, gastrointestinal, or skin and mucous membranes. These organisms are transmitted to the potential susceptible host through very many ways, but it has been reported that contact is the most common method of transmission of infection in the healthcare settings. Of them, direct contact, where person-to-person spread of infection through actual physical contact may happen, is by far the most common mode of cross infection. It should also be noted that indirect contact, which is a direct derivative of direct contact through contaminated inanimate objects can also serve as a potential source of acquiring cross infection. Simple hand washing is the most effective way to prevent such cross infections (Ojajarvi, J., 1980). Depending on the knowledge of these elements, the risk management strategy would involve all parameters of this chain of events. To save the patient from this risk, one would implement processes to control or eliminate the infectious agent, to control transmission, and to control the reservoir. If an infectious agent is recognized in a patient, the immediate step would be to place the patient with suspected or proven infectious disease under source isolation or under barrier precautions. To reduce the bioburden of microorganisms in the healthcare setting, a thorough cleaning of the environment is the best possible step to be employed. The control of transmission can be accomplished by hand washing, aseptic techniques, and control of the hospital ward environment. Proper hand washing, whether applicable to the healthcare personnel or the visitors, has been demonstrated to be effective in controlling the spread of infection in the patients (Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., and Touveneau, S. 2000). Basic aseptic techniques, hence, is a quality control and risk management measure, not only for sterile procedures or patient handling cares, but also for any potential contacts that the patients may face. To effectively manage the risk and to control transmission of microorganisms, it is essential that effective decontamination and stringent control of environment is exercised. Control of reservoirs, such as, other patients, visitors, and healthcare professionals, all of whom may play roles in transmission, can be effectively implemented by simple techniques to reduce bacterial burden in the reservoirs. An Adverse Clinical Incident Report Section 1: Incident Details: Where was the Incident Detected: The incident was detected in the Medical-Surgical ward of the hospital in the female ward, where this staff is posted as a staff nurse. Where did the Incident Originate: The incident originate in the same ward of the hospital during the visiting hour. When did the Incident Occur: The incident occurred on June 17, 2007, at 1800 hours. Who was involved in the Incident: This incident involved around the patient at bed 234 in the second floor Female Wing of the ward. The patient is a surgical patient with ventral hernia repair done on June 15, 2007. Apart from this, the patient also has co-existing chronic obstructive pulmonary disease and diabetes mellitus. This incident involves the visitors of the patient and the nurse in attendance of the ward. Names and Contact Numbers of the Staff who may be able to Provide More Information about the Incident: Name Number 1. 2. 3. 4. Immediate Outcome of the Incident: Clinical Event: The outcome of the incident was not evident, but a report of the incident would not be irrelevant. One of the visitors was noted to be coughing very loudly, and the visitor was noted to be touching the patient. This physical contact can be potentially harmful for the patient who has chronic obstructive pulmonary disease and diabetes. The physical contact without hand washing could easily transmit any potential infection to the patient who is diabetic. Diabetic patients are potentially prone to infection despite adequate control of blood sugars. A patient who has ventral hernia repair, infection can be not only detrimental to the outcome of surgery, with diabetes and chronic obstructive pulmonary disease in the background may have two effects. First, contracting infection in the surgical area may complicate situations and recovery, even failure of the surgery. Second, acute exacerbation of chronic bronchitis from infective event from droplet infection may lead to cough episodes that will put mechanical stress on the surgical area leading to failure of the surgery. Thus, this may lead to harm of the patient in near future, but truthfully, it is not clearly known whether the visitor was actually having a running infection. For the sake of safety, it is better to assume that the visitor might be a carrier without overt signs and symptoms of infection, and physical contact with a high-risk patient like this may tantamount to violation of risk management strategies in the word; at least, the visitor was not instructed on hand washing before approaching the patient with a physical contact that could potentially lead to a cross infection. This report aims to notify the incident because even if it did not constitute a clinical event of uncertain or unknown implications apparently leading to no event, it is at least sufficient to constitute a dangerous practice on the part of the visitor, and this can be termed as a near-miss event that reached the patient probably compromising the safety of the patient. Clinical Events Only: This is not considered as a clinical event; therefore, the name of the consultant and patient's number or date of birth are not applicable, hence not reported. The patient was a post surgical patient, and the patient was not involved in any clinical studies. Section 2: Brief Description of the Incident: This reporter was on duty at the visiting hours on June 17, 2007. The time was 6 p.m. in the evening. The patient was supposed to have blood sugar check as per the consultant's instruction. This reporter approached the patient at her bed. At that time, this reporter noticed that a visitor was holding the hand of the patient. This is very common in the ward, when visitors forget the clinical setting, and they try to encourage the patients. I noted the visitor coming in a little while ago, so it is natural that the visitor did not wash her hands. This perhaps is a risk management issue, since in this reporter's view and knowledge, this event may affect safety of the patient. If the patient acquires a cross infection, this would lead to increased stay in the hospital and might increase morbidity of the patient. Section 3: Immediate Response to the Incident: This reporter immediately reported this incident to the superior, and the superior came and called the visitor and explained the risks and outcomes of potentially unhygienic contacts with the patient. The visitor was asked to wash hands and then allowed to come back to the patient. Section 4: Incident Category: This incident falls in the category of healthcare-acquired infection. This can be productive of cross infection due to poor environmental hygiene due to hands not washed by the visitor and/or poor washing techniques. This can be termed as inadequate measures to prevent cross infection. Member of Staff Reporting the Incident: Nursing staff. Design of Risk Management Package: This package will systematically apply management policies, procedures, and practices to the task of analysing, assessing, treating, and monitoring risks of cross infection in the hospital setting. The intent of this package is to provide the staff with a tool to assist with prospective and retrospective identification of the cross infection risk in order to reduce adverse outcomes for the patient, thus improving patient safety and ensuring high-quality service (Birch K. 2004).. To achieve this, every staff is responsible to systematically identify, analyse, treat, monitor, and report risks associated with any activity, function, or process. This risk management process will depend on a specific guideline to prevent cross infection in the hospital ward. The risks should be rated by the responsible supervisors. The guidelines will assist the staff and the organization to develop specific plans for the management of such risks. To turn this plan into the business of every personnel involved in patient care, it is extremely important that such risk management plan be incorporated in the hospital's business plan (Department of Health 1999). Establishment of the Context: The first step in the risk management plan is to establish the environmental context within which the unit operates. To delineate the extremely complex environment of healthcare in the hospital ward setting, an effective risk management strategy must consider the strategic plan of the hospital authority, the goals of the unit, the harmony between cost-benefit and opportunity, the correlation between risk management activity and other projects, and finally, other sub-environments, specially, the client within the facility (Department of Health, 1997). Identification of the Risk: There are three context areas of the risk, strategic, operational, and external. A risk workbook that is developed based on quality plan format. This would help assess and identify the risks despite change in the environmental conditions. The ideal method would be to identify risks before they present challenges. To be able to do this, a well-structured and systematic process of prospective risk identification that encompasses even the risks that are beyond organizational control, for example, environmental. The other way is to identify risks is to identify it in a retrospective manner. A stringent review process is necessary to identify these. These processes are designed to detect episodes of risks as a consequence of noncompliance with policy to prevent cross infections. To accomplish this, units are consistently encouraged to continue ongoing screening of incidents and complaints regarding even suspected situations which constitutes a breach of safety policy that might surmount to be a risk. The most important aspect is that there must be an efficient reporting system of the risks. The risks should be documented (Mayatt, V.L., 2004). The Risk Analysis: Once the risks are identified, there should be a process of analysis as to whether this is a minor, moderate, or major risk. On a scale of 1 to 5, the consequences of the risk are to be rated. There should be a likelihood rating, that is, how likely it is that the event would occur, and if it occurs, at what frequency, this might occur. Lastly, the overall risk should be determined by consequence rating and likelihood rating. All analyzed risks that may be termed as extreme and high risk are to be discussed with the higher authority (Department of Health, 2000). Evaluation of the Risks: The evaluation of the risk is done in order to decide whether the risk is tolerable or not. Low-risk incidents do not require any specific treatment in the available resources. Risks evaluated to be not tolerable are actively managed. If the risk is determined to be tolerable, it must be monitored. There are certain risks where no treatments are available. The cost-benefit of treatment may outweigh the risks, and in that case, the risk becomes acceptable (National Patient Safety Agency, 2004). Management of Risk: Treatment of the risks would include identification of the range of options for managing the risks, assessment of the options, preparation of risk treatment plans, and implementation of the treatment plans. For example in the case of cross infection through the visitor, a general guideline for infection control in the ward is in play, and physical contact with the patient in the ward is violation of those guidelines. Strictly abiding guidelines would prevent many infections, and all staff is required to follow them. The standard package for prevention of cross infection of organisms or bacteria from one person to another can be prevented by safe work practice, and violation of such would lead to a risk. The safe work practice applies to all persons involved in the patient's care and having possibility of coming in contact with the patient, patient's blood and bodily fluids, saliva, intact and non-intact skin, and mucous membranes (Steere, A.C. and Mallison, G.F., 1975). The preventative measures that can be used to take care of spread of cross infections are mainly thorough washing of hands, cleaning the exposed surfaces of the patient, staff, or visitor with quaternary ammonium compounds, disposing tissue secretions in appropriate bins; when handling the patient, observing excellent and stringent hygienic practices; and maintaining safe and non-contact distance during visiting hours (Sanderson, P.J. and Weissler, S., 1992). The procedures that may be followed strictly is hand washing rigorousness. The work area must be clean. This can be accomplished with disposable paper towels with a premixed solution containing quaternary ammonium chloride solution. Through washing of hands of anybody coming in contact with the patient must be mandatory. Hands should be washed with running warm water and soap. The hands should be dried with an air drier or disposable paper towels. The staff is supposed to wear gloves over and above it to prevent transmission of bacteria from one patient to other (Larson, E.L., Early, E., Cloonan, P., Sugrue, S., and Parides, M., 2000). The Hand-washing Risk Management Package: Most common diseases are spread through hands, and hands are often contaminated. Hand washing as a method of decontamination is the best method of prevention of cross infection. The policy should be hands should be decontaminated before and after every patient contact irrespective of the person making that contact. For the visitors, a routine handwashing can be recommended. A routine handwashing can be effective in reducing both surface and deep seated microorganisms. Hands should be washed and dried before and after every patient contact (Taylor LT., 1997). Comment: Although this sounds to be a good package, there are drawbacks in this package. Hand washing is known to be the most important aspect of preventing nosocomial infection through contact. The duration of time of hand wash is the most important parameter. Plain soap and water can be effective partly to accomplish bacterial load of contact partly; it is important to use antiseptic agents, such as, alcohol-based solutions to achieve maximum safety. It also has a part of education inherent in it. Only monitoring and reporting would not produce results unless all involved understand the importance of hygiene and hand washing practices in reducing nosocomial infections and hazards out of it. Reference List Ayliffe, G., Lobury, E., Gedded, A., and Williams, J., (1995). Control of Hospital Infection, 3rd ed, Ch 6, Chapman & Hall, London. Barach, P. and Small, S.D., (2000). Reporting And Preventing Medical Mishaps: Lessons From Non-Medical Near Miss Reporting Systems. British Medical Journal; 320: pp. 759-763. Birch K. (2004). Healthcare Standards and Risk Management. Keele University: Health Care Standards Unit. Boyce, J.M., (1999). It Is Time For Action: Improving Hand Hygiene In Hospital. Annals of Internal Medicine; 130:pp. 153-155. Department of Health, (1997). The New NHS, Modern, Dependable. London: The Stationery Office. Department of Health, (1998). A First Class Service: Quality In The New NHS. London: Department of Health. Department of Health (1999). Implementation of Controls Assurance. Health Service Circular 1999/123 London: Dept of Health. Department of Health, (2000). An Organisation With A Memory. Report Of An Expert Group On Learning From Adverse Events In The NHS. London: Department of Health. Department of Health, (2000). An Organisation with a Memory: Report of an expert advisory group on learning from adverse events in the NHS. London: The Stationery Office Infection Control Nurses Association (ICNA), (2003). Guidelines for Hand Hygiene. ICNA in collaboration with DEB, Bathgate, London. Larson, E.L., Early, E., Cloonan, P., Sugrue, S., and Parides, M., (2000). An Organizational Climate intervention associated with increased handwashing and decreased nosocomial infections. Behaviour Medicine;26: pp. 14-22. Leape, L.L. and Berwick, D.M., (2000). Safe Health Care: Are We Up To It British Medical Journal; 320: pp. 725-726. Mayatt, V.L., (2004). (2nd Edition) Managing Risk in Healthcare Law and Practice. London: LexisNexis UK. Moss, F., Palmberg, M., and Plsek, P., (2000). Quality Improvement Around The World: How Much We Can Learn From Each Other. Quality Health Care;9: pp. 63-66. Moss, F., Garside, P., and Dawson, S., (1998). Organisational Change: The Key To Quality Improvement. Quality Health Care;7 (Suppl 1):S1-S2. National Patient Safety Agency, (2004). Seven steps to patient safety: An overview guide for NHS staff. London: NPSA (Second print April 2004). Ojajarvi, J., (1980). Effectiveness Of Hand Washing And Disinfection Methods In Removing Transient Bacteria After Patient Nursing. Journal of Hygiene (London); 85: pp.193-203. Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., and Touveneau, S. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet;356:pp.1307-1312. Sanderson, P.J. and Weissler, S., (1992). Recovery Of Coliforms For The Hands Of Nurses And Patients: Activities Leading To Contamination. Journal of Hospital Infection; 21: pp. 85-93. Seddon, M.E., Marshall, M.N., and Campbell, S.M., (2001). Systematic Review Of Studies Of Clinical Care In General Practice In The United Kingdom, Australia, And New Zealand. Quality Health Care; 10:pp.152-158. Steere, A.C. and Mallison, G.F., (1975). Handwashing practices for the prevention of nosocomial infections. Annals of Internal Medicine;83: pp. 683-690. Taylor LT., (1997). An Evaluation Of Handwashing Techniques. Nursing Times;74: pp. 54-55. Thomson, R., (1998). Quality To The Fore In Health Policy-At Last. British Medical Journal; 317:pp. 95-96. Appendix Hand Washing Risk Management Package 1. The procedures that may be followed strictly is hand washing rigorousness. 2. The work area must be clean. 3. This can be accomplished with disposable paper towels with a premixed solution containing quaternary ammonium chloride solution. 4. Thorough washing of hands of anybody coming in contact with the patient must be mandatory. 5. Hands should be washed with running warm water and soap. The hands should be dried with an air drier or disposable paper towels. 6. The staff is supposed to wear gloves over and above it to prevent transmission of bacteria from one patient to other. 7. Most common diseases are spread through hands, and hands are often contaminated. 8. Hand washing as a method of decontamination is the best method of prevention of cross infection. 9. The policy should be hands should be decontaminated before and after every patient contact irrespective of the person making that contact. 10. For the visitors, a routine handwashing can be recommended. 11. A routine handwashing can be effective in reducing both surface and deep seated microorganisms. 12. Hands should be washed and dried before and after every patient contact. 13. Continuous monitoring of the ward environment is necessary. 14. Any breach of standards is immediately reported. Read More