The Cause of the Patient Safety Issue - Essay Example

CRITICAL INCIDENCE REPORT Name Course Instructor Institution Date Critical Incident Report Health care professionals take up different roles including the promotion of patient safety through the provision of quality care services. Despite patient safety being a major concern in health care, there still exist instances where a mistake made by a health care professional may result in patient harm. However, the occurrence of these mistakes often results in a blame game, where one professional passes the liability to another resulting in a disintegrated system with no learning opportunities. Recent years have however seen a shift in the handling of patient safety issues, which includes the use of critical analysis. A critical incident analysis involves a study of the patient safety issue, including steps that should have been taken to prevent the issue (Anderson, et al., 2013, p. 3). Anderson, et al. (2013, p. 8) explained that the use of critical analysis allowed health professionals to learn from their mistakes; therefore, improve their patient safety practices in the future. This report entails the findings of a critical incident analysis of a patient safety issue involving the inappropriate administering of intravenous medication by a new nurse in the hospital. The report includes a description of the situation including an explanation of what happened and what should have happened, as well as an analysis of the roles played by the different health professionals within the department. This analysis will allow an understanding of the cause of the patient safety issue; therefore, provide a response to the incident. Incident Description Medicines account for the most commonly used treatment method employed in the Australian healthcare especially when administered and used correctly. However, errors in the medical administration are quite frequent with the error rates ranging between 19-27 % (Westbrook, et al., 2011, p. 1028). These medicine administration errors present more serious problems as compared to other medication errors, with the effects affecting both the health professional and the patients. Simple errors may lead to serious outcomes including death in the patient and a long lasting impact on the nurses’ professional career. Intravenous medications present some of the highest risks especially due to the different steps employed in the preparation and administration of the drugs. In Australian hospitals, the rate of IV medication errors is estimated at 70% with most of these errors occurring due to wrong mixtures, and wrong dilation (Australian Commission on Safety and Quality in Health Care, 2012). The scenario under study mainly revolves around an intravenous administration error conducted by a new nurse in the hospital. The nurse in question was administering intravenous medication to a patient without properly diluting the medication, which would have resulted in the patient experiencing a negative reaction or even death. In the scenario, the senior registered nurse supervising the first year RN did not pay much attention to how the IV medication was prepared, which resulted in the first year RN administering wrongly diluted medication. The issue occurred during the lunch break, which illustrates that it was not a busy day, as different staff members had already gone for lunch. RN are required to act as supervisor to student nurses and first year RNs especially on an issue related to medicine administration. Reid-Searl and Happell (2011, p. 140) explained that the supervisory role partaken by RNs puts them at risk of legal action especially when medication errors occur due to negligence. In the scenario, both the senior RN and first year RN share the legal responsibility for the error resulting from IV medication administration. Other than just determining the issue, the critical incident analysis also involves a description of the right procedure, which allows an understanding of where exactly the mistake was made. One of the major mistakes conducted in the scenario was the lack of supervision, which was mainly the RNs fault. Before administering the medication, the first year RN asked a senior RN to clarify on how the medication should have been diluted. Rather than just agreeing with the first year RN, the supervising RN shroud has confirmed the dosage. According to Reid-Searl and Happell (2011, p. 140), the RN is required by law to act as a supervisor during the preparation and administration of medications, as first-year RNs and student nurses lack the required experience to avoid simple errors such as the issue of medication dilution. The RN supervision is only one of the steps that could have ensured minimization of the error. Another step that could have helped prevent the error was the adherence to the six right of medication administration. According to Government of Western Australia: Department of Health (2013), nurses administering medication should consider six steps, which are the use of the right drug, the right time, the right documentation, the right dose, the right patient, and, right route. The first year RN, administering the drug did not have sufficient knowledge on the medication dosage, which resulted in him administering a dose that was not properly diluted. The first year RN had his doubts on the medication dosage, which prompted him to ask the RN. However, rather than asking one RN, the nurse administering the medication should have consulted with another RN to ensure all doubts regarding how the medication was to be diluted were cleared. As explained by the Australian Commission on Safety and Quality in Health Care (2012) IV medication administration should involve two people, which are the individual administering the IV, as well as another individual who is required to check and confirm the various details regarding the drug including the dose, and patient information. In the scenario, the various details were not confirmed, which resulted in the error occurring. Other than the supervising RN, another registered nurse should have been present from preparation to drug administration. Critical Analysis of the Scenario Although the critical incident reveals errors by both the supervising RN and first year RN, analysis of the scenario should involve an investigation that focuses on more than the actions of these two individuals. Mahajan (2010) explained a framework developed by Vincent, Rodgers, Woloshynowych, and Taylor-Adams as the most effective when analyzing critical issues in health care. The critical analysis framework discussed by Vincent et al., (2005) as stated in Mahajan (2010) explains that rather than placing focus on front row staff, analysis of critical incidences should aim at studying the whole spectrum, which allows for the development of multi-level strategies meant to reduce errors. The framework provides a description of six major factors that may influence the occurrence of errors in medication administration. In the scenario organizational, individual and team factors are the main contributory factors to the IV medication error. Individual Factors Individual factors including lack of enough knowledge, skills, health and competence all played a role in the occurrences of the error (Mahajan, 2010). The first year RN lacks enough knowledge and experience concerning the administration of IV medication. The lack of knowledge on the right procedure of IV medication administration may be one of the factors that contributed to the incident (Unver, et al., 2012, p. 318). The first year nurse has only had a few weeks clinical experience; therefore, may not fully understand how to dilute the IV medication. Other than lacking knowledge on the right procedure of administering medication, the first year RN may also have been unaware of the health policy, which requires the presence of another RN to double-check the various aspects of the medication. Although the nurse in question explained that he had consulted another nurse, the first year RN should have ensured there was another nurse in the vicinity during medication administration. Actions conducted by the supervising RN also contributed to the incident. Medicine administration should incorporate more than one nurse, where one of the nurses takes the supervisory role. However, in the incident, the first year RN was alone, while administering the medication, which illustrated incompetence on the supervising RN’S side. Reid-Searl and Happell (2011) conducted a study, which explained novice RNs to receive limited supervision during medicine administration. The lack of supervision may have been because of the supervising RN being busy with another patient. Eklof, et al., (2014) explained the need for RN to employ team strategies as a way of ensuring patient safety, especially during busy days. If the supervising RN was busy during medical administration, he or she should have appointed another nurse to help supervise the IV administration. ON the supervising RN part incompetence and lack of a team, planning skills may have been a contributory factor to the incident. The lack of knowledge on medication procedures may also be another individual factor contributing to the incident. According to Ramasamy, et al. (2013), explained a high percentage of Australian nurses to employ single checking, due to lack of knowledge on the various benefits of double checking medication. In the scenario, the first year RN only employed the single checking process, which may have resulted in errors in calculation. If there was no other nurse to double check the medication, the first year nurse should have employed calculations from other nurses, as a way of double-checking the medication. Other than the lack of knowledge on medication procedures, as well as the lack of supervision, other individual factors that may have resulted in the incident include hunger, stress and health issues (Glavin, 2010). The incident occurred during the lunch break; therefore, the mistake may have been a result of the first year RN’S hunger. The first year RN also lacks experience in clinical practice, which may result in him getting tired faster than other experienced nurses get. Such fatigue may also act as a contributory factor to the incident. Team Factors The health care environment involves different professionals performing different duties, with all being aimed at promoting positive patient outcomes. Errors in medications may occur due to issues affecting the multi-disciplinary team, with the major factors likely to contribute to errors being poor communication, poor team culture and poor supervision (Mahajan, 2010). Medical administration involves the participation of different professionals including doctors, pharmacists, and nurses. The pharmacist is often the one who releases the drug to the nurse or doctor. As such, the pharmacist should act as an advisor to the health profession regarding the dosage, as well as the correct route of administration (Brady, et al., 2009). Interdisciplinary communication plays a huge role in the prevention and reduction of medication errors. The novice nurse was unsure of how to dilute the medication, and should have consulted the pharmacist on the best dilution. Murphy and Dunn (2010) explained the need for inter-disciplinary communication between nurses and other professionals, which would help prevent mistakes caused by false assumptions. In the scenario, poor communication between the different professional may be act as a contributory factor to the incident. Poor communication may also exist between the novice nurse and the senior RN nurse. The medication error may have occurred due to the supervising RN having poor communication skills. Although the supervising RN was consulted on how to prepare the medication, they gave a wrong answer, which may show a lack of concentration or a negative attitude towards the novice RN. Other than communication between the team members, the reporting of medication errors is also another team factor likely to have prevented the occurrence of the medical error. Patterson, et al. (2013) explained that increased instances of medication error reporting resulted in reduces incidents involving medication errors. Medical error reporting by the different professionals involved in health promotion promoted learning, and as such ensures errors are not committed again. The reporting of incident errors and increased communication between team members would help promote a positive team culture; therefore, promote the prevention of medication errors in the future. Organizational Factors Organizational and institutional factors greatly influence both individual and team factors. The political environment, financial factors, safety climate and management decisions have a significant impact on patient safety issues (Mahajan, 2010). These various factors relate to the hospital and the university where the novice RN studied. The working environment plays a huge impact on the performance of employees. Financial factors including the lack of adequate finances to increase the number of personnel working in the hospital may be one of the issues contributing to the occurrences of the error. Inadequate staffing may result in nurses being fatigued due to working with numerous patients. Other than the issue of fatigue, inadequate staffing may result in reduced supervision, which in turn may have been the reason for the occurrence of the error. Other than inadequate staffing, protocols and guidelines set by the hospital administration play also play a significant role in preventing or promoting the occurrence of medical errors. An organizational guideline likely to have an impact on medication errors is that of double-checking medication before administering. Ramasamy, et al. (2013) explained that a high percentage of RNs did not have a complete understanding of the double checking concept especially due to poor definition of the process in hospital guidelines and protocol. As mentioned in the previous section, the IV medication was not double-checked as the novice RN was in the room alone with the patient, which may indicate little definition of the double checking protocol in the hospital guidelines. The safety climate of the hospital also plays a huge part in influencing critical medical incidents (Mahajan, 2010). The organizational culture of the reporting of medical errors and near misses also plays a major role in the incident. Frequent reporting of medication errors by professionals promotes learning, which in turn results in prevention of the various errors. Medical personnel, however, avoid reporting medication errors due to the fear of reprimand, which often results in other individuals making the same mistake. A negative organizational culture concerning the reporting of errors may have been a contributory factor to the incident. The institution where the novice RN trained at may also influence the occurrence of the error. Reid-Searl, et al. (2013, p. 112) explained institutions to have both the legal and moral responsibility of ensuring their students have sufficient knowledge on different health care issues including medication administration. In the scenario, the novice nurse makes the mistake due to lack of knowledge on how the IV medication should be diluted, which may indicate a failure on the part of the training university. Zahara-Such (2013) explained a need for nursing training institutions to incorporate advanced instruction approaches as a way of ensuring nurses who graduate have adequate knowledge regarding medical administration. Response to Incident The main aim of developing a critical incident report is to ensure that all dynamics pertaining medical errors are understood; therefore, act as a learning opportunity to help prevent similar incidents in the future. The first step to take during the scenario would be an attempt to stop the error from continuing as ignoring the incident may have resulted in the possibility of an adverse event occurring. However, in the scenario, the novice RN claims to know what he is doing, which would result in me approaching another senior RN to advise on the situation. Reporting to the relevant authorities would help to ensure that the medication administration does not continue any further. The South Australian government health procedures require hospitals and health facilities to conduct investigations to determine the factors that promoted the incident (SA Health, 2016). After reporting, the hospital will have to review reports to determine the cause of the medication error. Analysis of the incident should focus on the failures of the both individuals, team, and the organizations, as well as provide recommendations on how future incidents may be avoided. The various recommendations offered by the critical analysis should employ a multi-targeted approach that addresses organizational, individual, and team factors resulting to the medication error. Other than employing a multi-targeted approach, management of the incident should target at ensuring continuous improvement by employing a positive approach. As I am still a novice RN, I would use the incident as a learning opportunity. One of the activities to ensure the incident is a learning opportunity will involve maintaining non-blaming communication with the nurse who committed the error as well as with the supervising RN. The incident should also act as a learning opportunity for all the individuals involved. Rather than playing the blame game, the various parties affected by the incident should work together to prevent the reoccurrence of such an event. Such cooperation may involve openly communicating with one another, which may result in sharing of ideas on how the hospital, university, teams, and individual health promotion can help improve patient safety in the hospital. Conclusion Patient safety ranks among the most prominent issues affecting healthcare organizations internationally. Incidents regarding patient safety have resulted in death or other adverse effects on the patient’s death. Traditionally, the handling of critical incidents involved a lot of blaming and finger pointing, which in turn resulted in incidents reoccurring. Modern approaches, however, employ critical incident reports, which focuses on factors other the individual who committed the error. The use of a critical incident report allows focus on the multi-disciplinary team, the various organizations as well as individual factors. As opposed to traditional approaches that made the individual as the main point of concern, critical incident reporting places organizational factors as the most likely to promote the occurrence of medication incidents. As such, recommendation offered in the critical incident report, mainly focus on strategies meant to improve the overall safety culture of a health organization. The various strategies explained by the critical incident report should focus development of effective communication networks, promotion multi-disciplinary collaboration, and open incident reporting. However a critical incident report may not address all variables, therefore, the need for more study on better ways of managing critical incidents; therefore, reduce medication errors to almost zero. References Anderson, J. E., Kodate, N., Walters, R. & Dodds, A., 2013. Can incident reporting improve safety? Healthcare practitioners’ views of the effectiveness of incident reporting. 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Improving Medication Calculations of Nursing Students through Simulation: An Integrative Review. Clinical Simulation in Nursing, 9(9), p. e379–e383. Read More