Identify a patient care case from your own practice experience that involves quality and safety. Note: If you are not practicing or have not practiced, use a case that has received media attention or one from the textbook.

QUESTION

Identify a patient care case from your own practice experience that involves quality and safety. Note: If you are not practicing or have not practiced, use a case that has received media attention or one from the textbook.

Summarize the situation.

Describe your (or the nurse’s) role in the patient care situation.

Explain the role the patient played in their own quality- or safety-related situation.

Evaluate the relationship between the patient’s care and the outcome.

Identify how the care environment affected the situation, including the nurse or provider, the patient, and the outcome.

Determine whether a quality model was employed. If yes, identify and explain it. If not, identify one that could have improved the situation.

Explain what actions you might take to improve the outcome or prevent an adverse outcome in the future.

ANSWER

Patient Safety Incident: Medication Error

Introduction

In my practice experience, I encountered a patient care case involving quality and safety that centered around a medication error. This incident exemplifies the significance of effective communication, thorough medication reconciliation, and patient engagement in ensuring optimal patient care and minimizing adverse outcomes.

Situation Summary

The patient, a 70-year-old female with a complex medical history, was admitted to the hospital for management of heart failure exacerbation (Van Der Horst et al., 2007). As part of her treatment, she required multiple medications, including diuretics, beta-blockers, and angiotensin-converting enzyme inhibitors (ACE inhibitors). Unfortunately, during her hospital stay, a medication error occurred when the nurse administered the incorrect dosage of the ACE inhibitor.

Nurse’s Role

As the nurse involved in this patient care situation, my responsibility was to administer medications according to the prescribed orders. However, in this instance, there was a breakdown in the medication administration process, leading to an error.

Patient’s Role

The patient played a crucial role in this quality- and safety-related situation by actively participating in her care. She had a comprehensive knowledge of her medical history, including her medication list, and consistently provided accurate information to the healthcare team. Her involvement and willingness to ask questions about her medications were instrumental in identifying the error and mitigating potential harm.

Relationship between Care and Outcome

The patient’s care directly impacted the outcome of this situation. The medication error could have resulted in serious complications such as hypotension, renal impairment, or electrolyte imbalances. However, due to the patient’s vigilance and open communication, the error was promptly identified and corrected, mitigating any adverse effects.

Impact of the Care Environment

Several factors within the care environment contributed to this medication error. First, there was a lack of standardized processes for medication reconciliation and double-checking during medication administration (Tariq, 2023). Additionally, communication breakdowns between healthcare providers and inadequate documentation of medication changes further compromised patient safety. These factors highlight the need for a more robust system that emphasizes medication safety and encourages effective interdisciplinary collaboration.

Quality Model

In this case, a quality model was not explicitly employed. However, the implementation of a model such as the Plan-Do-Study-Act (PDSA) cycle could have improved the situation. The PDSA model involves developing a plan, implementing it on a small scale, evaluating the results, and making necessary adjustments. By applying this iterative model, the healthcare team could identify vulnerabilities in the medication administration process and implement targeted interventions to prevent errors in the future.

Improving Outcome and Preventing Adverse Events

To enhance the outcome and prevent future adverse events, several actions could be taken. First, implementing standardized medication reconciliation protocols upon admission, transfer, and discharge would ensure accurate medication lists and reduce the risk of errors (Rodziewicz, 2023). Second, enhancing communication and collaboration between healthcare providers through structured handoff processes would facilitate seamless care transitions. Third, promoting patient engagement and education regarding medication management would empower patients to actively participate in their own care, identify potential errors, and ask pertinent questions.

Conclusion

The patient care case involving a medication error highlights the importance of quality and safety in healthcare. It underscores the critical role of effective communication, patient engagement, and a supportive care environment in preventing adverse events. By employing quality models like the PDSA cycle and implementing targeted interventions, healthcare organizations can continuously improve patient care, enhance patient safety, and reduce the occurrence of medication errors.

References

Rodziewicz, T. L. (2023, May 2). Medical Error Reduction and Prevention. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499956/ 

Tariq, R. A. (2023, May 2). Medication Dispensing Errors and Prevention. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519065/ 

Van Der Horst, I. C. C., Voors, A. A., & Van Veldhuisen, D. J. (2007). Treatment of heart failure with ACE inhibitors and beta-blockers. Clinical Research in Cardiology, 96(4). https://doi.org/10.1007/s00392-007-0487-y