Improving Patient Care: Infection Control And Risk Management In Surgical Centers (essay).

You are the Chair of the Department of Surgery at a large urban Medical center. The infection control nurse makes an appointment to see you and review infection data she has been gathering over the last year. Although you have had regular meetings with and reports from her, she felt it was important to go over some data that was somewhat disturbing.

She presents data that indicate; the medical center has an unusually site infection rate following gallbladder surgery. The rates are three to four times higher than the national average.

In the meeting, you addressed several questions and asked for prompt answers, however, she states that she doesn’t yet know the answers and will start conducting a detailed investigation

After meeting with the Perioperative Director, the infection Control Nurse, and the Chief of General Surgery, you have initially determined some of your previous questions. However, you asked again the infectious disease control nurse to meet with the head of pathology and the doctor in charge of infectious disease for more investigation of this critical issue.

The questions:

• What are the questions you should ask to the infectious Control Nurse in the first meeting to investigate the case?
• What kind of inputs you could receive from the Chief of General Surgery, and the head of pathology department?
• What are the clinical, financial, and legal implications of these infections?
• Prepare a plan for promoting workplace safety, and highlight on those preventing infections from occurring in the future for both Patients and Staff.

Questions: 

1. “Risk management means clinical care”, reflect on this statement as per the article view.

2. Assess quality of healthcare in outpatient clinics using Maxwell classification. “follow the example of intensive care unit shown in box 2”

3. The article reflects on “ineffectiveness of healthcare” by providing some examples, provide TWO more examples from your own.

4. The article proposed some characteristics of total quality management, do you think we have further points to add?

5. How risk management programs can interact with the Donabedian’s, Maxwell ‘s classification of quality. Explain this using each category of these classifications

Choose one topic we went through this course that related to your facility service delivery, and set up a report addressing “problem and suggested solutions” OR “Situation Analysis with proposed future Actions.

Report outline:

• Introduction and background
• Objective
• Data of inputs
• Analysis and discussion
• Recommendation & Suggestions

Task 1:

Q1.  

• Which are the methods you are well versed for infection control?
• Which are the methods your practiced to collect data and analyse it for infection control ?
• Have you undergone any specific training for infection control and if yes, can you brief about the training?
• Are you aware of the guidelines for infection control?
• Whether our facility is following Government and WHO guidelines for infection control ?
• Describe in short roles and responsibilities of the head of infection control department?
• Is our facility made any written infection control policy ?
• How much time you are spending on infection control programme ?
• What are the commonly used disinfectants useful to prevent surgical site infections?
• Which are the most common microorganisms responsible for surgical site infections?  
• Which is more efficient method for disinfection; local or systemic?

Q2.

Chief of General Surgery can provide data about risk factors associated with the patient. Older age of the patient, treatment with immunosuppressive agents and malnutrition are mainly responsible for occurrence of infection in patients. Chief of General surgery can also provide input related to the operative procedure which are responsible for surgical site infection (SSI). Factors related to operative procedure include hair removal, inappropriate use of antimicrobial prophylaxis, duration of the operation and wound classification. Chief of General Surgery can also give input related to the policies and procedures required for control of surgical site infections. Information about operation room and isolation precautions can also be obtained from Chief of General Surgery. Head of the pathology can provide information about the extent and depth of infection. This information would be helpful in assessing how old infection was? Input related to type of microorganism like gram positive and gram negative can be obtained from head of pathology. Information about appearance of incision can be obtained from head of pathology (Fuller, 2017).       

Q3.

It has been estimated that approximately 38 % nosocomial infections occur due to surgical site infections. SSI can occur in three forms like superficial SSI, deep incisional SSI and organ or space SSS. Superficial, deep incisional and organ SSI can occur within one month, upto one year and after one year respectively. Infection in the SSI mainly depends on the type of surgery. Abdominal surgery can lead to infection due to mixed gram positive and gram negative microorganisms, while extra abdominal surgery lead to infection due to S. aureus and staphylococcoal infection. SSI can produce abscess formation in patients which is associated with swelling, pain, redness and warmth. Cellulitis, bacteraemia and urinary tract infection can occur in patients with SSI.

Surgical site infection can increase readmissions to the hospital. This can produce huge financial burden on patients. Moreover, repeated hospital vissits can lead to reoccurrence of infection in SSI patients. Hospital need to improve facilities for patient care hence there might be augmentation in financial burden on the hospitals for improving healthcare facilities. Hospital need to keep bed of patient with infection free for few days which can lead to less revenue for the hospital. Surgeon would be in dilemma prior to surgery due to more incidence of SSI (Shepard et al., 2013; Jenks et al., 2014).

Q4.

• World Health Organisation (WHO) recommendations should be implemented for infection control and for providing safe environment in the hospital.
• Environmental safety Service Staff should be recruited.
• More emphasis should be given for disinfecting surgical aids and hands during surgery.
• Meetings should be conducted among all the stakeholders on regular basis to prevent occurrence of infection.
• Validated room cleaning checklist should be implemented.
• High touch areas should be given more attention for disinfection.
• Personal protective equipment (PPE) should be kept outside operation theatre and patients room. (Isaacson, 2012)

Q1.

Risk management can be beneficial in reducing errors which can produce harm to the patients and ultimately reduce financial burden on the patient. Hence, risk management can be beneficial in improving overall quality of the patient care. Risk management can implement coherent approach to improve patient care. Risk management can predict harm to the patient, hence precautions can be taken to reduce this harm. Risk management can improve complete procedure of care to the patient.  

Task 2: Case Study

Q2.

Maxwell’s classification is based on different criterias like effectiveness, efficiency, relevance, acceptability, access, and equity.

Effectiveness: Outpatient clinics have highly qualified staff well versed with medical procedures and skills and implement suitable technology.

Efficiency: Outpatient clinics operate at low cost and produce optimum work with existing staff. It maintains proper electronic record of patients which is helpful in improving efficiency of care to the patients.   

Acceptability: Outpatient clinics provide seats and lounges in the waiting room for the patients and their relatives.  Concerns of the patient and family members transfer effectively to clinicians and feedback from the clinicians pass on to the patient and family members.  

Relevance: In outpatient clinics, there is appropriate use of all the resources for improving health of the patients.

Access: Outpatient clinics are easily accessible and care can be provided within stipulated timeline without long duration waiting.

Equity: There is no discrimination of the patient based on factors like social, cultural, financial and ethnic.

Q3.

Medical error reporting, its discussion and corrective measures for these errors are important components of patient safety. In hospitals with multiple departments, medical errors are being reported less often due to insecurity of loss of job.

Insufficient communication among medical staff of various departments. This might be due to ban on use mobile phones in the hospital premises during official working hours.

Q4.

Additional characteristics include:

• Highly qualified and trained management staff.
• Acceptability of change in the process in the hospital during transformation.
• Sustained quality improvement programme.
• Implementation of changes according to the requirements of the global changes.
• Implementation of effective communication system.
• Healthcare staff and patient management.

Q5.

There is interaction between risk management and Donabedian’s, Maxwell’s classification of quality. This interaction can be demonstrated by providing platform to fix the characteristics of quality and planning measures to eliminate deficiencies to achieve quality. Risk management is important aspect in the healthcare organisation because serious issues can arise from the medical errors.

Effectiveness:  Risk management can be helpful in understanding skill levels of staff, equipments and modern technologies for meeting quality compliance. It can also be helpful in achieving desired output for the patients and aim for the organisation. Risk management is helpful in implementing required changes to avoid medical errors and implementing effective quality.

Efficiency: Risk management make sure that there is cost effective and optimum utilization of the resources for improving quality in healthcare organisation. Risk management also ensures that there should not be unnecessary outcome of the intervention in the healthcare facility.  

Relevance : Risk management ensures that there is relevant data collected for assessing health of patient. Moreover, it also ensures that appropriate intervention is provided to the patient.

Task 3:

Acceptability: In risk management there is provision for collection of responses form the patient and these responses can be utilised for improvement in provision of healthcare services to the patients and achieve complete satisfaction for the patients.

Access: Risk management assess reasons for not receiving appropriate intervention for patients and its potential financial impact on the patient and hospital. Higher authorities in the risk management department design strategies for improving access of appropriate healthcare intervention to the patient. It would also be helpful in reducing adverse effects to the patients due to less access to the healthcare interventions.

Equity: Risk management ensures that provision of medical services is devoid of bias and these medical services should not vary based on social, financial and cultural aspects of the patient. Risk management analyses rise of adverse effects due to unequal provision of healthcare services. It also ensures provision of strategies to minimize these adverse effects.

Medial error can be categorised in two classes like error of execution and error of planning. Error of execution include failure in administering planned medications and error of planning include implementation of wrong plan to achieve desired outcome in the patient. Medical errors are one of the most significant health problems. Since, long time medical errors are responsible for the comprised patient safety. Medical errors not only affect patients but it also affects family members. Staff also get affected due to medical errors because ethical issues might arise due to medical errors, moreover staff might lose job due to medical errors. Medical errors can produce huge financial burden on the hospitals for providing supplementary health intervention and expenditure might also come through Lawsuit. Medical errors and it consequences can be effectively managed by implementing regulated healthcare services in the hospital. Effective reporting and management of the medical errors can be regulated by making compulsion of licenses to the healthcare facilities and it should be regulated by federal bodies.  It is evident that majority of the medical errors do not occur due to solely human errors, however defective process and systems in the organisation are major contributors for the medical errors (Reason, 2001). Inadequate skill for the implementation of processes and variable processes are also responsible for medical errors (Kalra, 2011).

Potential outcomes of the medical errors mainly based on the type of patient like inpatient or outpatient and procedure like surgery or medication. For the prevention of medical errors, effective strategy need to be implemented. Medical error prevention strategy should include validated processes and systems. These processes and systems should include prevention of human errors and plan to compensate adverse events which would arise due to human errors. Multiple strategies should be implemented like patient education, government regulations, government investment and hospital policy. Medical errors can impact health, social and economic wellbeing of the patient (Nguyen and Nguyen, 2016).

This study is designed not only to identify problems which can arise due to medical errors but also solution would be provided to solve these problems. These solutions would be based on the literature and validated methodologies. More attention would be given to the identification of the errors and accurate reporting of the errors.

Objectives:

• To identify reasons for occurrence of medical errors in the healthcare facility.
• To provide solution to prevent medical facility.
• To implement validated and well researched method to identify reasons for medical errors.
• To provide solution to prevent medical errors based on evidence.

Data and inputs:

In this study, data was collected from 100 physicians and 200 nurses from the 50 hospitals. Data will be collected by implementing semi-structured interviews because in this frame work of interviews questions can be modified slightly based on the persons. Questionnaires will be prepared for each aspects of data collection. This data was collected by sending questionnaire through mail and response was received through mail. Ethical and confidentiality consideration were made during data collection to prevent bias in the data. These include identity and occupation of patient, physician and nurse were confidential. It helped in giving honest response. Data provider should have knowledge about the medical errors. Hence physicians and nurses were selected for the data collection. Patients were not considered for the data collection because patient might not aware of the details of the medical errors. Collected data was arranged in the Excel sheet. Both qualitative and quantitative data was collected during the study.

Following were the questions included in the questionnaires :

Q1. What is the age and experience of physician and nurse and what is the frequency of medical errors ?

Fig 1: Relation between age of Physician and Nurses and percentage of medication errors.

Age	Percentage of medication errors
25 – 50 yrs	25 %
51 – 60 yrs	75 %

 
Q2. Which are the most common practices with more frequency of medical errors ? In this question five categories were selected like diagnosis, surgery, medication administration, lab report and equipment error. Frequency of errors in these categories were evaluated on five point scale.

Fig 2: Relation between medical practices and medication errors.

Medical practices	Percentage of medication errors
Diagnosis	20 %
Surgery	5 %
Medication administration	30 %
Lab report	35 %
Equipment error	10 %

Q3. Which are most common causes of medical errors related to humans ? In this question four causes related to human were selected like patient’s misunderstanding, nurse and physician’s insufficient knowledge, miscommunication among healthcare providers and patients and lack of technical expertise in medical and paramedical staff.

Fig 3: Relation between human factors and medication errors.

Human factors	Percentage of medication errors
Patient’s misunderstanding	15 %
Insufficient knowledge	20 %
Miscommunication	45 %
Lack of technical expertise	20 %

 
Q4. What is impact of the medical errors on the economic status of the country ? or Whether medical error is the financial burden on the on the country?

Fig 4 : Economic burden on the country

Strongly agree	Not agre
65 %	35 %
Surgery	5 %

 
What ate the initiatives taken to address the problem of medical error  and which are the organisations taking initiative to reduce problem of medical error ? What is your opinion about these efforts ?

Satisfied with the methods	Not satisfied with the methods
70 %	30 %

 
Q5. What are the available strategies, techniques, procedures and methods to prevent medical error ? Which are the methods, you are aware of for the prevention of medical errors ? According to you which are the most effective methods available for the prevention of medical errors ?

• Providing raining to medial and paramedical staff.
• Improvement in the technology.
• Availability of adequate financial resources.
• Providing individual level care to patients.
• Sparing extra time with patients.

 Q6. Are you spontaneously taking actions to minimize the adverse effects occurred due to medical errors ?

Yes	No
70 %	30 %

 
Q7. Are you accurately reporting medical errors ?

Yes	No
70 %	30 %

Q8. Have you undergone training for reducing medical errors ?

Yes	No
65 %	35 %

 
There were logical approaches to select these questions. Question related to age was asked to understand effect of older age on the medical errors. Even tough older people are good in techniques, they are more susceptible for errors. Question related to different divisions of healthcare facility was asked because medical errors not only can occur due to manual error of medication administration but it can also occur due to problem in the instrument and faulty reports (McGlynn et al., 2003). Questions related to manual errors was asked because different behavioural and intellectual aspects might be responsible for the medical errors. Question related the financial condition of the country was asked because strong financial status of the country mainly based on the overall health of the population. Health of people in a country can be improved by reducing medical errors. Question related to reporting of the medical error was asked because there should be accountability of the medical errors. This accountability record should comprise of type of medical error, severity of it and responsible person for it. This data would be helpful in taking measures to prevent repeated occurrence of these medical errors. Knowledge and skills can be helpful in preventing medical errors, hence question related to it was asked to the participants (Kalra, 2011).

Analysis of data:    

It is evident form the data that age of the physician and nurses can be contributing factor for medical errors. 70 % physician and nurse above 50 years of age accepted that they are responsible for the medical errors. One of the prominent reasons for occurrence of medical errors due to older healthcare professionals might be due to overload of work and they need to look after multiple aspects in the healthcare facility. It has been observed that healthcare professionals with experience between 3-6 years are more prone to medical errors. Errors in the lab reports are the major contributing factors for medical errors. There are more chances of medical errors in lab report because preparation of lab report involves multiple staff. Moreover, in diagnostic lab multiple samples can be handled at the same time for the preparation of lab reports. Hence, there is more possibility of errors in lab reports. Miscommunication among different stakeholders is also one of the prominent factors responsible for the occurrence of medical errors. Miscommunication among different stakeholders might occur due to healthcare providers with less knowledge, lack of mobile phones during working hours and information transfer error during shift changes. Medical errors can have significant impact on the financial aspects of all the stakeholders like patient, family members, hospital and Government. It is evident from the data that currently implemented measures for the prevention of medical errors are acceptable for the majority of the healthcare professionals participated in the study. Majority of the healthcare professionals participated in the study agreed that provision of training to the medical and paramedical staff would be beneficial in reducing medical errors. Accountability and record keeping of the medical errors are beneficial in reducing frequency of medical errors and taking necessary actions for adverse reactions arise due to medical errors. Risk assessment and management is one of the prominent aspect which can be helpful in reducing medical errors. Risk management involves more focus on the aspects like improvement in the accuracy of lab reports, improvement in the communication among different stakeholders and provision of training to the medical and paramedical staff.  

This study can be considerd as the model study and it can be implemented for larger population of healthcare professionals. It would be helpful in achieving more robust data. Findings of this study can be extrapolated to the similar types of multispeciality hospitals, however these findings can not be extrapolated to clinics. Findings of this study comprises of multiple aspects which can be learned and implemented by healthcare professionals. Healthcare professionals need to be thoroughly well versed with the theoretical aspects of medical services and processes, prior to the implementation to the actual practice in the clinical setting. Healthcare professionals need to be high on their confidence and moral because these aspects would be helpful for them in reducing medical errors. Physicians should establish effective communication with other healthcare providers like nurses, pharmacist, pharmacy technician and lab technician. Physician should communicate with the other stakeholders through both written and verbal form (Cohen, 2007).    

Problems related to medical errors can be identified at individual level and at the system level. Problems at the individual level can also occur due to problem at the system level. It is difficult to monitor medication errors because frequency and severity of medical errors are not evenly distributed among patients, doctors and drugs. Hence, efforts should be made to identify high risk factors responsible for medical errors. Medication errors can be identified by direct observation, voluntary reporting by healthcare staff and chart review.  

Management should take responsibility to provide all the facilities and modern technologies for reducing medical errors. There should be regular upgradation of equipments according to the international standards. Automatic medicine dispenser should be upgraded on regular basis and training for newly introduced automatic medication dispenser should be provided to all the stakeholders. Management should take extra efforts to improve engagement of the employees by giving intensives and rewards (Waluube, 2011; Dean et al., 2002). Employee engagement can reduce employee turnover and there is less requirement of training sessions for reducing medication errors. Management should recruit sufficient number of employees, which would be helpful in reducing employee burnout. It would also be helpful in reducing employee workload. Reduction in employee workload is one of the prominent reasons responsible for the reducing medication errors. There should be development of special department for medication errors. This department should continuously monitor medication administration, laboratory reports and diagnosis reports. This department should provide training to reduce medication errors to other healthcare staff. Management should allocate special budget for reducing medication errors (Berntsen, 2004; Gebauer et al., 2017; Bonnabry et al., 2008).   

Physicians and nurse should implement novel and innovative methods to reduce medical errors. Physicians and nurses should provide education related to medication to the patient and family members. It would be helpful in reducing medication error because healthcare providers mistake can be corrected by the patient and family members. Even though it is not possible for the healthcare providers to give attention to individual patients, these healthcare providers should spare extra time for the patients. It would be helpful in building healthy relationship with the patients and medication rejection by the patients can be avoided (Hammoudi et al., 2017). Government should implement strict regulations and laws related to the medication errors. There should be provision for implementation of penalty for physicians associated with medical errors on regular basis. There should also be provision for cancellation of medical license in cases of serious health issues of patients. Government should keep track of all the trends of medication errors and preventive strategies should be implemented for the high risk causes of medication error (Gartshore et al., 2017).  

Human error is one of the prominent reason identified for the medication error, hence automation systems should be implemented in the facility. Computerised systems for the entry of prescriptions and billing should be implemented. Automated entry of prescriptions and delivery of medications would be helpful in monitoring excess or less amount of medications. Moreover, it would also be helpful in dispensing accurate medication with prescribed dose and dosage form. Bar coding should be provided to the medicines, blood, medical devices and patients (Litman et al., 2017). There should be provision of automated software systems for identifying abnormal laboratory data and clinical decision making. Automation can improve quality of care in the facility, however it is also associated with certain potential errors and possibility of breakdown. All the stakeholders should be trained to identify potential errors and breakdown. These stakeholders should be able to trouble shoot the problem (Kadmon et al., 2017).

Healthcare providers should adhere to the policies and procedures for reducing medical error. These healthcare providers should be aware of modern technologies, information accessibility, near misses, teamwork, communication, collaboration, patient safety and compliance. Healthcare providers should be aware of application of HFMEA (Healthcare Failure Mode and Effects Analysis) for patient safety and compliance. Healthcare providers should take leadership role in promoting quality care and safety to the patients. Medical errors can be effectively controlled by implementing evidence based practice. Moreover, evidence should be collected and documented which would be helpful for the future doctors to reduce medical errors. Broader framework should be implemented to reduce medical errors. This framework comprises of design, implement, process, evaluate and analyse methods to eliminate medical errors. Healthcare services comprises of diverse processes which include human operators and application of modern technologies. Hence healthcare providers should take all the precautions to eliminate errors both from human operators and modern technologies (Hepler and Segal, 2003; Mekonnen et al., 2017). Responsibility of patient safety should be shared by all the members of the hospital. There is possibility of medical error at each stage of patient care, hence healthcare providers should take care at each stage of patient care. Multiple individuals and services need to be implemented for patient safety.

Six sigma can be used for improving, designing and monitoring processes required for reducing medical errors. Efficiency of the medical error reduction programme can be effectively evaluated by comparing data at the baseline and after implementation of the solutions for reducing medical errors (Guinane et al., 2004). Toyota Production System/Lean Production System can be used in reducing medical errors. This method mainly depends on the identifying root cause analysis for identification of errors and implementation of quality improvement programmes to reduce medical errors. Evidence available for application of Toyota Production System/Lean Production System by physicians, nurses, pharmacist, technician and managers in improving quality of care to the patients by reducing cost of care (Spear, 2005). Root cause analysis can be used to identify risks to reduce errors in case of suspected human errors. Root cause analysis is important aspect in reducing medical errors because human errors are mainly responsible medical errors. Healthcare service is labour intensive service. Due to diverse nature of these healthcare staff, there is more possibility of errors in medical services (Giacomini et al., 2000). Failure modes and effects analysis (FMEA) can be implemented to address known and unknown failures. Hence, it can be implemented to address the issues prior to their occurrence. There is opportunity to implement alternative procedure and monitor change over the time to reduce medical errors (Day et al., 2006).

Prevention of medical error mainly depends on the detection of errors and improvements in the medical services. Accurate reporting of the medical errors can be helpful in giving warning and disseminating information to other stakeholders. It would be helpful in taking corrective action for medical errors.

References:

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