Quality Improvement Initiative Essay Discussion Paper
Brief explanation of the QI initiative you selected, and why.
The selected quality improvement (QI) initiative is improved communication at nurse handover during shift change. This is an issue of interest because a shift change involves new personnel coming in to take on nursing care responsibilities. The concern is that the communication at shift change does not adequately prepare the incoming nurses to handle the needs of the patients (Stanhope & Lancaster, 2020). With enhanced shift change communication, it is anticipated that four quality areas will be improved. First, care effectiveness will be improved by reducing unnecessary waste of time while improving patient satisfaction and experience as the incoming nurses will get all the information they need from the outgoing nurses. Second, improve care effectiveness as the change will result in measurable improvements to patient outcomes and safety, provider wellbeing, and process efficiency. Third, improved safety as the change will enhance the ability of nurses to give patients the best possible care. Fourth, it will ensure that shift change process delays are eliminated, reduce roadblocks and make it easier for nurses to deliver value (Sherwood & Barnsteiner, 2021).
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Explain how adverse events are handled in your healthcare organization or nursing practice, including an explanation of how this may impact both public and internal perspectives on healthcare quality.
Adverse events are not unusual in the hospital environment and are caused by medical treatments that cause injuries to patients. There are many causes of adverse events to include device/equipment failure, medication and surgery resultant of a substance within the medication or human error. In addition, it is important to note that an adverse event may occur as a side effect during treatment or as an unintended effect. Besides that, there are occasions when the occurrence of an adverse event is anticipated and accepted, often when the benefit of treatment is greater than the adverse event as a temporary harm (Sherwood & Barnsteiner, 2021).
The hospital has adopted a standard operating procedure for handling adverse events. The first step is creating a safe, non-judgmental space in which to make timely reports about adverse events. Second, having a plan for handling individual adverse events with a focus on legal expectations, such as knowing who to report to and how, along with timeliness expectations. Third, identifying a good communicator to handle all communications with patients. A good communicator has good communication and listening skills, and knows how to approach difficult subjects with different audiences. Fourth, contacting and involving a malpractice insurance carrier if necessary. Fifth, assessing records to determine the source of the adverse event. Finally, determining solutions and applying systemic fixes (Kaakinen et al., 2018).
Briefly describe the error rate from the article you selected, and explain how this may relate to your healthcare organization or nursing practice.
Liukka et al. (2020) reports on how adverse events affects different stakeholders perceived as first, second and third victims. The first victims suffer direct harm, second victims are the medical personnel who experience physical or emotional distress from the adverse event, and third victims who are the organizations that experience business difficulties from the event. Of particular interest is the second victims who include all the providers who are involved in care delivery and may blame themselves for the adverse event thus causing them to suffer physical or emotional distress. The study reveals that approximately 30% of providers who care for patients who experience adverse events become second victims because of that event. The article clarifies that the prevalence of second victims varies between 10.4% and 43.3%. This is important information as it reveals that while the occurrence of an adverse event may affect the patient directly, it also effects the providers. This shows that even as a solution is developed for the patients, the providers should not be ignored (Liukka et al., 2020). As such, the article justifies investment in interventions targeting nurses and other providers whose patients experience adverse events.
References
Kaakinen, J. R., Coehlo, D. P., Steele, R., & Robinson, M. (2018). Family Health Care
Liukka, M., Steven, A., Moreno, F. V., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (2020). Action after Adverse Events in Healthcare: An Integrative Literature Review. International Journal of Environmental Research and Public Health, 17(13), 4717. https://doi.org/10.3390/ijerph17134717
Sherwood, G., & Barnsteiner, J. (Eds.) (2021). Quality and Safety in Nursing: A Competency Approach to Improving Outcomes (3rd ed.). John Wiley & Sons.
Stanhope, M., & Lancaster, J. (2020). Public Health Nursing: Population-Centered Health Care in the Community (10th ed.). Elsevier, Inc.
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Post a brief explanation of the QI initiative you selected, and why. Be specific. Explain how adverse events are handled in your healthcare organization or nursing practice, including an explanation of how this may impact both public and internal perspectives on healthcare quality. Then, briefly describe the error rate from the article you selected, and explain how this may relate to your healthcare organization or nursing practice. Be specific and provide examples. Review the Learning Resources for this week, and reflect on the types of quality improvement (QI) initiatives that might be most relevant to your healthcare organization or nursing practice. Select a QI initiative, you are most familiar with, that has received support from your senior leaders in your healthcare organization or nursing practice. Consider how adverse events are handled in your healthcare organization or nursing practice. Reflect on how this may impact the public—as well as the internal—perspective on healthcare quality. Find a scholarly article or one from the public press, published within the last 5 years, that recounts a serious error. Reflect on this error, and consider how it may relate to your healthcare organization or nursing practice Quality Improvement Initiative Essay Discussion Paper