Risk Management and Patient Safety: Diane was an 80-year-old resident who was returning to the nursing home from the hospital following a left hip fracture on Friday evening. She has a history of congestive heart failure with frequent exacerbations. Her hospital discharge medication list was different than the prior medication list at the nursing home, specifically relating to her Lasix prescription. Diane was already taking Lasix at the nursing home before her hip fracture. All of her medication orders were transcribed by hand onto a new medication administration record (MAR). The old MAR, prior to the hospital stay, was not removed. The nurse checked Diane’s new orders and wrote “repeat” next to the new Lasix order and yellowed out the line. She was interrupted and was not able to finish reviewing the orders so she asked another nurse to review it for her. The second nurse reviewed the order and saw that the old MAR was still there. She removed the old MAR and finished reviewing the new MAR.
On Sunday, the medication nurse passed meds for Diane, as she had done for the past three days. She saw the yellowed line through the Lasix order and thought that the medication had been discontinued. She sent the medication back to pharmacy. Pharmacy picked up the medication on Monday. On Monday, it was noted that Diane weighed three pounds more since being discharged from the hospital. The nurse recorded the weight and placed a call to the physician, who failed to respond. At 2:00 a.m. Tuesday morning, Diane began to have difficulty breathing. Assessment findings included 4 pitting edema, a BP of 190/110, a HR of 120, and respirations at 28. Crackles were heard through her lungs. The on-call physician was consulted and an order was placed to transfer Diane back to the hospital. She went into cardiac arrest while waiting for the ambulance and was not able to be resuscitated.
Provide your risk analysis for this event. Develop an action plan for the prevention of events like this one in the future. Which theory or model would you apply in developing your action plan?
Information provided from Professor that may be useful
Swiss Cheese Model is a well known model in health care for organizational accidents. This model uses swiss cheese as a demonstration that there are several lines of defense put in place to reduce the likely hood of an error occurring. The holes in each of the levels represent a pore design the will allow that error to occur. If the holes begin to align, the likelihood of the error to occur is high. When these occurences happen, it is difficult to blame it on any single person. These events occur because of several different failures on each level. Once an investigation occurs, this becomes more apparent that multiple failings in processes created this issue, not one individual. It is not a normal occurrence that healthcare workers come to work with the intention of deliberately not doing their job and jeopardizing a patient’s safety. Therefore when an event occurs, you must ask staff members why they think the event occurred. What processes may have failed and any other issues that contributed to the event. From a leadership point of view, a policy or procedure may be simple but employees may feel very different as they are putting the processes into play. Because of this, staff members often create shortcuts in order for them to complete their tasks. The Incident Pit Model is the ability to be aware of small situations and understand that these situations can turn into a much bigger problem if it is not taken care of right away. Taking care of minor incidents will allow you to see what other issues might be taken care of. This process of reviewing even small issues will reduce the risk to an organization, by preventing larger problems down the road that could potentially result in serious and negative outcomes. Hindsight Bias is one, one is able to predict the outcome after the event has already occurred. These individuals will mention that they could have seen a certain event happening based on current processes. When investigating an event, hindsight bias implies that because the outcome was foreseeable, it could have been prevented. If the incident could have been prevented, then events leading to the incident are likely seen as mistakes and bad judgement. Hindsight bias can hinder a true investigation. Looking back on events and putting blame on one individual or one mistake is not acceptable and can cripple an organization, because other aspects will not be looked at. Heinrich established the Domino Theory based on the following consecutive five points. Ancestry and Social Environment, process of acquiring knowledge of customs and skills in the workplace, lack of skills and knowledge of performing tasks, and inappropriate social and environmental conditions will lead to fault of a person. Fault of Person results of carelessness in unsafe acts and or conditions. Unsafe Act and/or Mechanical or Physical Condition. Unsafe Act and or Conditions, including the errors and technical failures that caused the accident. Accident, caused by the unsafe act or conditions that subsequently lead to injuries. Injury, consequence of the accidents.
Risk Analysis
Once a risk is identified, the next task is to measure its impact on the enterprise. Certain risks can have different effects on an organization. Quantitative analysis is needed once a risk is identified in an organization. It is good to know the history of events that occurred in the past. This can help predict the future and assure that implementation trends in the right direction. With modern technology in place, many of the incident reports can be analyzed through a quantitative program. This process requires data collection so that analysis of the data can be reviewed for trends and patterns. Looking at these issues can identify the different levels of losses within an organization.
Losses can be identified by different layers. The bottom layer represents the losses that an organization can easily predict, and have a high frequency of occurring. The top layer represents a lower frequency of occurring, but also a higher and more severe risk. This top layer is very important and one occurrence in this layer can hurt an organization severely. The middle layer represents situations or events between the top and bottom, and is a moderate level of risk and occurrence (Poplin, et al., 2015; Dickson, 1995).
Being able to breakdown losses into these layers can help an organization truly understand the different levels and effects of different types of risk. This understanding will in turn help with decision and implementation of the risk prevention strategies for these different levels as the risk levels in the top may not have the same implementation plan as a risk that is on the bottom. These three levels also help with visual presentation to audiences and key stakeholders.
