Quality improvement is a structure that is employed to regularly improve the ways care is delivered to patients (Agency for healthcare, research and quality (AHRQ), n.d.)
“Prevention of hospital acquired pressure injuries in the medical ICU”. Hospital acquired pressure injuries (HAPIs) negatively impact the quality of life in patients in that it is painful, costly and is associated with other risks including death. Development of stage 3 and stage 4 pressure ulcers denotes poor patient care by the Centers for Medicare and Medicaid Services (CMS) and institutions get to cover the costs of such ulcers and its complications (AHRQ, n.d.). The financial burden on institutions and public report of poor patient outcomes in institutions have led to measures put in place to prevent the occurrences of HAPIs.
Organizations have different channels of commands when adverse events occur. My organization handles hospital acquired pressure injuries (HAPIs) as follows: When HAPIs happen on a unit, data on the patient is sent by the nurse to PIRC which is data collection platform. Such data is reviewed every Tuesday by the Unit Manager, Quality Controls personnel and the Manager of the Inpatient Wound care nurses. They look at patient’s comorbidities and preventive measures that were in place prior to HAPI occurring. They look for any gaps that would have led to the development of HAPIs. An educational tool is done from the collection of data and followed weekly. However, if this problem persists in a unit despite education, and changes in processes as deemed necessary, the CMO, Quality Controls personnel and other members of leadership are notified so that jointly they would come up with a sustainable plan.
The development of HAPIs, specifically stages 3 and 4 pressure ulcers is considered a “never event” according to Rondinelli et al. (2018). When this happens, such event is report to the Centers for Medicare and Medicaid Services and this result in decrease in reimbursement (Rondinelli et al. 2018). Also, this data is made public and the reputation of the organization in providing safe care is at risk. Thus, institutions are working hard to prevent these from occurring to avoid financial losses and also gain the confidence of the public in providing safe and quality care to patients entrusted in their care.
Da Silva et al. (2016) provided a case study on a medication error and recommendations of how this can be avoided in healthcare settings. This case involves a 71y/o female with a medical history that includes hypertension and was prescribed Norvasc 10mg to be taken twice a day. The pharmacist accidentally filled Navane, an antipsychotic medication instead of Norvasc. This patient took this medication for 3 months unnoticed, until the development of adverse effects including abnormal movements and a fall. During her 3 months of being on this medication, she was seen by multiple providers but this was not traced until her 3rd presentation to the hospital in which her medication bottles were reviewed. Then, it was noted that she was actually taking Navane, not Norvasc for hypertension (da Silva et al. 2016). This patient was failed by multiple providers including pharmacists, hospitalist and nurses, subsequently leading to an adverse event (da Silva et al, 2016). Recommendations to avoid such medication errors in the future include reviewing of pill bottles during medication reconciliation, having electronic health records in the institutions with software that allows for detailed information on prescribed medications, having two step medication review by providers upon admission and discharge, recommendations against providing refills on discharge prescriptions unless where absolutely necessary and promoting a system where pharmacists and physicians work closely together to review patient medications, among others (da Silva et al, 2016). Many institutions now have electronic health records but this does not take the place of providers carefully reviewing patient’s home medications, including looking at their pill bottles if available. Providers should educate patients to always carry their medications with them to every appointment to ease the process of medication review and reconciliation so that such errors could be caught in a timely manner.
Agency for Healthcare, Research and Quality (AHRQ), (n.d.) Practice Facilitation Handbook. Module 4. Approaches to Quality Improvement. https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod4.html
da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: a patient case and review of Pennsylvania and National data. Journal of community hospital internal medicine perspectives, 6(4), 31758. https://doi.org/10.3402/jchimp.v6.31758
Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-Acquired Pressure Injury: Risk-Adjusted Comparisons in an Integrated Healthcare Delivery System. Nursing research, 67(1), 16–25. https://doi.org/10.1097/NNR.0000000000000258